Introduction

The Patient Protection and Affordable Care Act’s Road to the Supreme Court of the United States

Coverage, accessibility, cost accountability and quality of health care are just a few of the issues the Obama Administration claimed to reform with the Patient Protection and Affordable Care Act (P.L. 111-148, PPACA). Proponents of the legislation praised how successful PPACA would be in addressing the woes plaguing the American health care system; opponents, however, projected the Act would do more harm than good. Despite PPACA being signed into law on March 23, 2010, and amended on March 30, 2010 by P.L. 111-152, the Health Care and Education Reconciliation Act of 2010 (HCERA), its provisions have been subject to legal debates over the statute’s constitutionality.

While the impact of the law is heavily debated, four primary arguments surround the debate against PPACA’s constitutionality before the Supreme Court. These include the individual mandate, the application of the Anti-Injunction Act, the lack of a Severability Clause in the statute, and the Medicaid expansion contained in the law. As of January 1, 2014, under the Patient Protection and Affordable Care Act, all U.S. citizens are required by law to either purchase qualified health insurance deemed so by the federal government or be covered under a government-sponsored program. If an individual chooses not to partake in either option a “tax penalty” of $95.00 or 1% of income, whichever is greater, will be imposed. By 2016, however, the penalty stands to increase to $695.00 for an uninsured adult up to $2,085.00 per household, or 2.5% of  income, whichever is more. (insert hyper-links for 4 arguments above)

Aside from issuing a “tax penalty,” the Patient Protection and Affordable Care Act will also issue employer penalties. By 2014 the health care law will require all businesses, larger than 25 full-time employees and eligible for a tax credit, to begin offering affordable coverage. If not, the employer is subject to penalties for either not providing any health insurance to their employees or not providing affordable enough coverage. The penalty for businesses who do not offer coverage, but have employees who have received a premium tax credit or cost sharing subsidy in an exchange, is $2,000.00 annually times the number of full time employees minus 30; increasing each year by the growth in insurance premiums. Additionally, employers that do not offer affordable coverage will pay a $3,000.00 annual penalty for each full time employee receiving a tax credit, up to a maximum of $2,000.00 times the number of full time employees minus 30. The penalty is increased similarly to the employers who do not offer any coverage at all--- each year by the growth in insurance premiums.

The most pressing argument against PPACA comes from opponents who argue Congress does not have the authority under the Commerce Clause to enact the individual mandate--- forcing citizens into health coverage or, essentially, charging them a fine. Many insist that the individual mandate is essential to upholding the entirety of the law and without it the law should fall. In support of their argument, opponents point to the lack of provision(s) within the U.S. Constitution guaranteeing a right to health care services from the government for those who cannot afford it; despite proponents who argue the power of Congress to enact the law exists within both the Commerce Clause and the Necessary and Proper Clause. 

Six challenges to the Patient Protection and Affordable Care Act arose within the U.S. District Courts; of those cases, two have been ruled on and two have been dismissed within the U.S. Circuit Court of Appeals. The first decision handed down on June 29, 2011, by the Sixth Circuit Court of Appeals in Cincinnati, upheld the entirety of the health care law. The second ruling was announced on August 12, 2011, from the Eleventh Circuit Court of Appeals in Atlanta. This decision found the individual mandate to be unconstitutional, but found the provision severable from the rest of the law. Therefore, the Eleventh Circuit issued their opinion that the rest of the law should still stand.

Despite the Eleventh Circuit finding that the “district court placed undue emphasis on the [PPACA’s] lack of severability clause,” it recognized the proximity of the severability question, with specific regard to two reforms under the health care law: guaranteed issue health insurance, and the prohibition on preexisting condition exclusions. The Eleventh Circuit’s opinion is important for three primary reasons. First, the court’s ruling establishes a circuit spilt because of the Sixth Circuit’s ruling that upholds the constitutionality of the individual mandate; meaning, Supreme Court review was anticipated. Second, this is the first decision handed down from a judge appointed by a Democrat to rule against the Obama Administration on the constitutionality of any provision within the health care law. Lastly, the Eleventh Circuit case has been considered, perhaps, the most important legal challenge to PPACA. This has much to do with the fact that 26 states have contested it, in addition to the National Federation of Independent Business, as well as, the questionability behind the validity of PPACA’s conditions on states’ access to federal Medicaid funds--- claiming them coercive.

On September 28, 2011, in response to the Eleventh Circuit Court’s ruling, the Justice Department petitioned the Supreme Court of the United States (SCOTUS) to decide the constitutionality of the individual mandate within the Patient Protection and Affordable Care Act; particularly asking for review of the Eleventh Circuit Court’s decision. The Supreme Court announced on November 14, 2011, that it would hear challenges against PPACA and granted a writ of certiorari in the case Florida v. HHS (Health and Human Services). By ordering a writ of certiorari, the Court enabled itself to review the decisions and proceedings of the lower courts, including the transmittance of records per case, through an appeal to determine whether any irregularities were made in original rulings.

Shortly following their announcement, SCOTUS also declared it would rule on the constitutional challenges on PPACA from two other appellate cases associated with Florida v. HHS including: U.S. Department of Health and Human Services (HHS) v. Florida (No. 11-393) and National Federation of Independent Business v. Sebelius (No. 11-393). The four central issues combined from the court’s decisions will be considered through an unusual 5.5 hours of oral arguments presented to the Supreme Court.

While the Court has already prioritized time for arguments regarding issues over the individual mandate, SCOTUS has also requested that both parties involved in Florida v. HHS raise the question of whether or not the suit violates the Anti-Injunction Act. This stems from whether the individual mandate qualifies as either a “tax penalty” or  a “fine” on the participants involved. Additionally, in the examination of The National Federation of Independent Business, a party to the Florida v. HHS lawsuit, the issue of severability will be discussed.

The oral arguments will begin on March 26^th and continue through March 28^th of this year. On March 26^th, SCOTUS will hear 1 hour of arguments on the Anti-Injunction Act. Day 2 will include 2 hours on the individual mandate, and day 3 will include 2.5 hours of debate regarding the Severability Clause and Medicaid expansion.

The United States Justice Department is remaining staunch in its argument that if the Court finds the health law’s mandate unconstitutional, it should only strike the community rating and guaranteed issue provision, not the entire law. Regardless of if or which way the Supreme Court rules on PPACA, their decision or lack-there-of will both economically and politically change U.S. health care history--- making it easily the most consequential and far reaching  issue to be debated before the U.S. Supreme Court since Brown v. Board of Education. 

Introduction

The Patient Protection and Affordable Care Act’s Road to the Supreme Court of the United States

Coverage, accessibility, cost accountability and quality of health care are just a few of the issues the Obama Administration claimed to reform with the Patient Protection and Affordable Care Act (P.L. 111-148, PPACA). Proponents of the legislation praised how successful PPACA would be in addressing the woes plaguing the American health care system; opponents, however, projected the Act would do more harm than good. Despite PPACA being signed into law on March 23, 2010, and amended on March 30, 2010 by P.L. 111-152, the Health Care and Education Reconciliation Act of 2010 (HCERA), its provisions have been subject to legal debates over the statute’s constitutionality.

While the impact of the law is heavily debated, four primary arguments surround the debate against PPACA’s constitutionality before the Supreme Court. These include the individual mandate, the application of the Anti-Injunction Act, the lack of a Severability Clause in the statute, and the Medicaid expansion contained in the law. As of January 1, 2014, under the Patient Protection and Affordable Care Act, all U.S. citizens are required by law to either purchase qualified health insurance deemed so by the federal government or be covered under a government-sponsored program. If an individual chooses not to partake in either option a “tax penalty” of $95.00 or 1% of income, whichever is greater, will be imposed. By 2016, however, the penalty stands to increase to $695.00 for an uninsured adult up to $2,085.00 per household, or 2.5% of  income, whichever is more. (insert hyper-links for 4 arguments above)

Aside from issuing a “tax penalty,” the Patient Protection and Affordable Care Act will also issue employer penalties. By 2014 the health care law will require all businesses, larger than 25 full-time employees and eligible for a tax credit, to begin offering affordable coverage. If not, the employer is subject to penalties for either not providing any health insurance to their employees or not providing affordable enough coverage. The penalty for businesses who do not offer coverage, but have employees who have received a premium tax credit or cost sharing subsidy in an exchange, is $2,000.00 annually times the number of full time employees minus 30; increasing each year by the growth in insurance premiums. Additionally, employers that do not offer affordable coverage will pay a $3,000.00 annual penalty for each full time employee receiving a tax credit, up to a maximum of $2,000.00 times the number of full time employees minus 30. The penalty is increased similarly to the employers who do not offer any coverage at all--- each year by the growth in insurance premiums.

The most pressing argument against PPACA comes from opponents who argue Congress does not have the authority under the Commerce Clause to enact the individual mandate--- forcing citizens into health coverage or, essentially, charging them a fine. Many insist that the individual mandate is essential to upholding the entirety of the law and without it the law should fall. In support of their argument, opponents point to the lack of provision(s) within the U.S. Constitution guaranteeing a right to health care services from the government for those who cannot afford it; despite proponents who argue the power of Congress to enact the law exists within both the Commerce Clause and the Necessary and Proper Clause. 

Six challenges to the Patient Protection and Affordable Care Act arose within the U.S. District Courts; of those cases, two have been ruled on and two have been dismissed within the U.S. Circuit Court of Appeals. The first decision handed down on June 29, 2011, by the Sixth Circuit Court of Appeals in Cincinnati, upheld the entirety of the health care law. The second ruling was announced on August 12, 2011, from the Eleventh Circuit Court of Appeals in Atlanta. This decision found the individual mandate to be unconstitutional, but found the provision severable from the rest of the law. Therefore, the Eleventh Circuit issued their opinion that the rest of the law should still stand.

Despite the Eleventh Circuit finding that the “district court placed undue emphasis on the [PPACA’s] lack of severability clause,” it recognized the proximity of the severability question, with specific regard to two reforms under the health care law: guaranteed issue health insurance, and the prohibition on preexisting condition exclusions. The Eleventh Circuit’s opinion is important for three primary reasons. First, the court’s ruling establishes a circuit spilt because of the Sixth Circuit’s ruling that upholds the constitutionality of the individual mandate; meaning, Supreme Court review was anticipated. Second, this is the first decision handed down from a judge appointed by a Democrat to rule against the Obama Administration on the constitutionality of any provision within the health care law. Lastly, the Eleventh Circuit case has been considered, perhaps, the most important legal challenge to PPACA. This has much to do with the fact that 26 states have contested it, in addition to the National Federation of Independent Business, as well as, the questionability behind the validity of PPACA’s conditions on states’ access to federal Medicaid funds--- claiming them coercive.

On September 28, 2011, in response to the Eleventh Circuit Court’s ruling, the Justice Department petitioned the Supreme Court of the United States (SCOTUS) to decide the constitutionality of the individual mandate within the Patient Protection and Affordable Care Act; particularly asking for review of the Eleventh Circuit Court’s decision. The Supreme Court announced on November 14, 2011, that it would hear challenges against PPACA and granted a writ of certiorari in the case Florida v. HHS (Health and Human Services). By ordering a writ of certiorari, the Court enabled itself to review the decisions and proceedings of the lower courts, including the transmittance of records per case, through an appeal to determine whether any irregularities were made in original rulings.

Shortly following their announcement, SCOTUS also declared it would rule on the constitutional challenges on PPACA from two other appellate cases associated with Florida v. HHS including: U.S. Department of Health and Human Services (HHS) v. Florida (No. 11-393) and National Federation of Independent Business v. Sebelius (No. 11-393). The four central issues combined from the court’s decisions will be considered through an unusual 5.5 hours of oral arguments presented to the Supreme Court.

While the Court has already prioritized time for arguments regarding issues over the individual mandate, SCOTUS has also requested that both parties involved in Florida v. HHS raise the question of whether or not the suit violates the Anti-Injunction Act. This stems from whether the individual mandate qualifies as either a “tax penalty” or  a “fine” on the participants involved. Additionally, in the examination of The National Federation of Independent Business, a party to the Florida v. HHS lawsuit, the issue of severability will be discussed.

The oral arguments will begin on March 26^th and continue through March 28^th of this year. On March 26^th, SCOTUS will hear 1 hour of arguments on the Anti-Injunction Act. Day 2 will include 2 hours on the individual mandate, and day 3 will include 2.5 hours of debate regarding the Severability Clause and Medicaid expansion.

The United States Justice Department is remaining staunch in its argument that if the Court finds the health law’s mandate unconstitutional, it should only strike the community rating and guaranteed issue provision, not the entire law. Regardless of if or which way the Supreme Court rules on PPACA, their decision or lack-there-of will both economically and politically change U.S. health care history--- making it easily the most consequential and far reaching  issue to be debated before the U.S. Supreme Court since Brown v. Board of Education. 

Interconnected: The Individual Mandate and Insurance Reforms

The Congressional Health Care Caucus is continuing its series leading up to the Supreme Court reviewing the Patient Protection and Affordable Care Act.  This forum will examine the codependent relationship between the individual mandate and insurance reforms and the effect removing one would have on the entire market.   

Alissa Fox, Senior Vice President – Office of Policy and Representation, BlueCross BlueShield Association

Tom Wildsmith Consulting Actuary, The Hay Group

Monday, March 5, 2012

11:30-12:30pm

2218 Rayburn House Office Building

Open to Members, Staff, Interns and the Public

Click here to watch online

To follow again, here is Alissa Fox's handout

Hosted by Rep. Michael C. Burgess, M.D.
Chairman, Congressional Health Care Caucus

For more information and to RSVP – Rebekah.West@mail.house.gov | 5-7772

The Arguments Before the Supreme Court

The Congressional Health Care Caucus will begin a new series leading up to the Supreme Court reviewing the Patient Protection and Affordable Care Act.  This event will focus on the arguments that will be presented to the Court against PPACA.

Karen Harned, National Federation of Independent Business

Colby May, American Center for Law and Justice

Open to Members, Staff, Interns and the Public

Hosted by Rep. Michael C. Burgess, M.D.
Chairman, Congressional Health Care Caucus

For more information and to RSVP – Rebekah.West@mail.house.gov | 5-7772

Preparing for the Future of Health Care in America

The Congressional Health Care Caucus will begin a new series leading up to the Supreme Court reviewing the Patient Protection and Affordable Care Act.  The purpose of this series is to discuss future policy ideas that will result as a decision is made by the Supreme Court.

Tom Miller, Resident Fellow at American Enterprise Institute

Jim Capretta, Fellow at the Ethics and Public Policy Center

Click here for Tom Miller's handout
Click here for Jim Capretta's handout 

  Tuesday, January 31

12:30-1:30pm  
2218 Rayburn House Office Building

Open to Members, Staff, Interns and the Public

Hosted by Rep. Michael C. Burgess, M.D.
Chairman, Congressional Health Care Caucus

According to statistics from the Center of Disease Control and Prevention, more Americans are killed by heart disease than by any other source. Our health care industry has made spectacular developments in the treatment of heart disease, and the outcomes of these treatments have improved by leaps and bounds. Despite these improvements, however, we are continuing to see this disease develop in many Americans, and at a younger age than ever. Recent studies indicate that children as young as 10 show evidence of arterial blockage and elevated cholesterol. This is undoubtedly one of the greatest health care challenges facing the state of Texas and the entire nation today. While our medical professionals must continue to seek out new and innovative treatment options, we as citizens should also focus on what we can do to prevent the disease. We need to educate ourselves about the risks and behaviors that lead to the disease. If we know about the risks, then we can properly adjust our behaviors. These actions, coupled with medical advancements, will put us in the best position to avoid disease and become a healthier nation.

When we use the term “heart disease” we are actually referring to a whole range of cardiac disorders. Some of the more common cardiac disorders include high blood pleasure, blocked arteries, heart rhythm and valve disorders, and heart failure. Many of these disorders can be worsened, or even caused, by another disease.

There are certain behaviors, or risk factors, that put one in the high-risk category for getting a form of heart disease. These risk factors are:

1.  Eating an unhealthy diet
2. Not getting enough exercise
3. Alcohol & tobacco use
4. Poor stress management
5. Improper management of other disorders

These behaviors can lead to a number of different life-threatening diseases, the most dangerous of which being heart disease. Hopefully this does not come as too big of a surprise.

Now that you know the risk factors, what can you do? Evaluate yourself. How are your behaviors in each category? If you have room for improvement in some behaviors, then focus on improving in those areas. Eat a healthier diet and get more exercise. Reduce your alcohol and/or tobacco use. Better yet, stop using them all together. Try doing a better job of managing your stress. I know this can be difficult, especially for type A personalities, but it will significantly reduce your risks for heart disease. Don’t be scared to indulge in a hobby, and do your best to get a full night’s sleep. Finally, you must be sure to properly take medication prescribed by your doctor for heart disease or other diseases. Always go to your follow up appointments. This is how your physician tracts and evaluates your progress, so it is absolutely vital.

Simply knowing the behaviors that put you at risk of getting heart disease is not enough. You must act. Prevention is the key. This does take discipline, but it doing so will greatly reduce your risks of getting heart disease. It can help you lead a higher quality and longer life. Who doesn’t what that?

Many people wonder what they can do to help control the cost of health care in this county. Well, properly maintaining current diseases and preventing future diseases are a few things that we can all do to help relieve some stress on our health care system. So let’s educate ourselves and put that knowledge to action so we can all leave healthier happier lives.

For the past few years diabetes has been one of the largest health problems facing many Americans. Diabetes is not only affecting the lives of millions of Americans, but it is doing so at an ever-increasing rate. In fact, the percentage of Texans with diabetes jumped from 6% to 13% between 2000 and 2010, and is expected to hit 15% by 2015. The numbers don’t lie. So it may be worthwhile to educate ourselves about diabetes. People without the disease can learn how to avoid getting it, while leading a healthier lifestyle and reducing risks for other deadly diseases like heart disease. Those individuals suffering from the disease can learn how to properly keep the disease in check, reducing the risks associated with diabetes, and possibly help control the nation’s staggering health care costs.

How does diabetes affect your physiology? Let’s start with glucose. Glucose is a small molecule that travels around in the blood stream to different parts of the body and is used as the body’s energy source. The body has a fascinatingly complex way of controlling the level of glucose in the blood stream. When the body needs to lower the level of glucose in the blood it releases a hormone called insulin. Type I diabetics are actually unable to make their own insulin and usually must rely on an outside pump that monitors their glucose levels and gives them small doses of insulin when necessary. Unfortunately, type 1 diabetes is genetic, so currently we can’t really do anything about it except treat it.

However, a person contracts type II diabetes – also known as adult onset diabetes – overtime when their cells are repeatedly bombarded with insulin for long periods. As this continues, the body becomes resistant to the affects of its own insulin. Therefore, they are unable to lower their blood glucose levels. When this happens glucose accumulates at high levels in the blood stream. If these high glucose levels persist untreated, they can cause all sorts of nasty symptoms. These symptoms may include increased thirst and urination, rapid weight loss, chronic infections, damaged blood vessels, kidney failure, blindness, and other possibly life threatening symptoms.

People suffering from the disease must not only live with its symptoms, but must also deal with how its treatment affects their lifestyle. For some individuals this may be constantly poking their fingers to check their blood glucose levels, taking oral medication, or adjusting their diet in such a way to maintain their diabetes. However, what often goes overlooked is the fact that diabetes also increases your risks of having heart disease, strokes, kidney failure, blindness, infections, and depression.

While many of us may be aware of the symptoms, life-style changes, and risks that people who have diabetes must live with, we often forget to see how the disease negatively affects our health care system. Many individuals suffering from diabetes and who cannot afford to properly maintain the disease may have to rely on emergency care for all of their diabetes treatment needs. This is extremely costly for our health care system. In order for hospitals to function they must pass these costs onto the rest of their patients, thus increasing health care costs for all of us.

It’s no wonder diabetes is such a deadly and costly disease. The good news is Type II diabetes is completely avoidable! If we know what causes the disease, then we can know how we can best avoid getting the disease. Obesity is the number one cause of type II diabetes. The lifestyle that leads most individuals to become obese is the same lifestyle that can lead one to become diabetic. So, we have to be conscious of the quantity and the quality of our food, and maintain reasonable daily activity levels.

It’s important to not overeat, but it’s also equally important to eat nutritious and well-balanced meals. Be sure that you’re getting your fruits and vegetables, and that you avoid greasy and sugary foods. We all live in a fast-paced world and many times have to eat on the run. We can literally be bombarded with a myriad of unhealthy food choices. I can’t stress enough how important it is to keep your own health in mind when deciding what to eat. Make it a habit to focus on the healthy items on the menu. This will go a long way in controlling insulin “spikes” that happen when you eat sugary greasy foods. It is equally important to get daily exercise. This has also been shown to steady insulin levels, thus lowering your risk of becoming diabetic.

While many of us may already be aware of the importance of eating right and exercising daily to maintain a healthy lifestyle, it can also help all of us avoid a potentially life threatening disease. Furthermore, by avoiding diabetes you can help our nation control the ever-rising health care costs.

Health Caucus Thought Leaders Series Featuring Ron Paul

Representative Ron Paul  will join the Health Caucus’ Thought Leaders Series to discuss his perspective on health care and his ideas on how to fix our current health care problems .   

Ron Paul, M.D., Republican Presidential Candidate and Member of the House of Representatives

Wednesday, November 16
12:30-1:30pm  
2218 Rayburn House Office Building

Open to Members, Staff, Interns and the Public 
Hosted by Rep. Michael C. Burgess, M.D.
Chairman, Congressional Health Care Caucus

For more information – Rebekah.West@mail.house.gov | 5-7772

Health Caucus Thought Leaders Series Featuring Herman Cain

Herman Cain will join the Health Caucus’ Thought Leaders Series to discuss his perspective on our current health care system and his health care initiatives for the future. 
 

Herman Cain, Republican Presidential Candidate  

Wednesday, November 2
1:15pm-2pm
Rayburn 2218

Hosted by Rep. Michael C. Burgess, M.D.
Chairman, Congressional Health Care Caucus

  Click here for the transcript from the event

See below for clips from outside news sources reporting on the event