Incredibly sad photo.
If America is a just and true nation, the Affordable Care Act will be strengthened, not repealed to redistribute wealth to rich guys.
This is not a cartoon. It’s real life.
Incredibly sad photo.
If America is a just and true nation, the Affordable Care Act will be strengthened, not repealed to redistribute wealth to rich guys.
This is not a cartoon. It’s real life.
Cartoon from Tom Toles at the Washington Post, April 2, 2014:
Why you need to know a little history to get good jokes:
Yogi Berra is famous for his sayings, some of which sound foolish at first, but which generally pack a lot of wisdom or sharp observation.
Berra grew up in St. Louis, which has many famous restaurants. On some occasion, someone suggested the group should go eat at Ruggeri’s, and Yogi’s reply became famous:
On why he no longer went to Ruggeri’s, a St. Louis restaurant: “Nobody goes there anymore. It’s too crowded.”
Here. NPR is our most trusted news organization, and it has answers to specific questions and a collection of great stories on the entire law.
Is that a coincidence, or did they plan it that way?
Your Questions About The Affordable Care Act
Wait a minute, you say: “I want answers to questions, not just news stories.”
Yeah, they know:
Find Answers To Common Questions
Get the picture? Click over there and start learning.
Then, when you’ve changed yoru health care plan (if you change it), come back here and answer this poll. It should go without saying that you can answer the poll now if you’re not going to change. Please answer only once.
Congressional Budget Office (CBO) figures show as many as 2 million Americans might quit jobs they don’t like, and go chase their dreams, because now they can get health insurance under the Affordable Care Act (ObamaCare).
Conservatives, and more than a few news organizations, misreported the study to say, as they claim, that the ACA will require the firings of 2 million people.
You can read the CBO report here, and draw your own inferences (make them reasonable, please); but Pat Bagley, the master cartoonist at the Salt Lake Tribune, put it in picture form. Several panels in this cartoon, each telling no fewer than a thousand words.
This is why the GOP doesn’t like ACA, you know. It really does give average citizens some choice. Freedom to choose NOT to feed the profit-gouging machines of the friends of the GOP threatens the GOP much more than did Americans drinking coffee instead of tea, in 1773.
Bagley’s cartoon is more than picture-perfect. It’s truthful.
After a convicted felon produced an edited video that appeared to show National Urban League “navigators” agreeing to allow the felon might file inaccurate information to get covered for health insurance under the Affordable Care Act, Republicans in Texas called for greater regulation of the navigators.
Such is the topsy-turvy world of GOP gotcha politics in Texas.
After committees of the U.S. House of Representatives held press conferences* damning the Affordable Care Act, the Texas Department of Insurance (TDI) is holding hearings across Texas to develop regulations to restrict actions of those people who act as navigators to enroll people into federal health insurance programs or private insurance through ACA.
In short, the Texas government is working to screw up federal law and deprive Texans of health care insurance (yes, that’s probably a felony, but who could prosecute it under the current political climate?).
On January 6th the Texas Department of Insurance will hold its last public hearing regarding the state’s regulation of health care navigators. The navigators are responsible for helping individuals get enrolled through the new Healthcare.gov exchange, but in Texas Governor Rick Perry has been working to add unnecessary red tape in order to impede the success of the law. Reputable non-profit organizations in Texas like United Way received $11 million in federal grant money to help enroll individuals in local communities across the state.
In September just days before the health insurance exchange website went live Perry ordered TDI to craft new rules that included additional training and background checks for individuals who serve as navigators. Apparently even Senator Kirk Watson the author of the bill (that authorized navigators in Texas) was unaware that TDI had sent a letter to federal Health and Human Services Secretary Kathleen Sebelius, or the plan to implement rules that, “appear to both conflict with federal law and be inconsistent with SB 1795.”
In other words, TDI’s actions, on orders from Gov. Rick Perry, may violate Texas law as well.
State Sen. Kirk Watson provided this testimony at the TDI hearings today:
Posted on January 6, 2014 at 10:12 am.
State Senator Kirk Watson issued the following statement Monday regarding the Texas Department of Insurance’s hearing on proposed rules for healthcare navigators:
Texans have made themselves heard, and it’s clear what they want: fair rules that truly protect consumers without making it harder for them to find health insurance.
The vast majority of healthcare navigators are honest folks who are working hard, and in good faith, to connect their fellow Texans with health insurance. The Department of Insurance should create regulations that protect the state from bad actors without making it harder for navigators to do their jobs.
Texans support common-sense requirements such as criminal background checks for navigators. The bill I passed in the legislative session allowing for navigator regulations prohibits convicted felons from providing these services. Of course the state should enforce that provision and protect consumers. We shouldn’t have electioneering; my bill prevents that too. And we need to be sure we protect privacy.
But some other proposed rules appear designed only to make it harder for navigators to do their jobs.
The Department of Insurance has proposed requiring 40 hours of navigator training on top of the 20-30 hours that’s already mandated by law. That kind of training requires real time and costs real money. Where did the additional 40 hour requirement come from exactly? Who is it truly meant to help? How will Texans benefit if navigators are spending as much as 200 percent more time in class? So far, TDI has failed to provide any explanation although repeatedly requested to do. If the Commissioner waits until the final rules are out, she robs Texans of a transparent, accountable process and avoids a fair debate on this issue.
It’s also patently unfair to assess fees on navigators who, by law, aren’t allowed to charge Texans for their services. The fiscal note on my original bill said the Department of Insurance could implement these rules using existing resources. Why is it now proposing these costly, burdensome fees?
I thank Commissioner Rathgeber for scheduling this second public hearing in response to my request for it. And I urge her to listen to the Texans she’s heard from in this process.
It’s wrong to impose heavy-handed, politically motivated rules that primarily serve to make life harder for hard-working Texans who are simply trying to help their friends and neighbors find affordable health insurance. Common-sense regulations should strike a balance that actually protect Texans, both by protecting their privacy and by protecting their ability to find good, reliable, affordable health insurance.
Sen. Watson also contributed more detailed suggestions in writing:
Posted on January 6, 2014 at 12:16 pm.
Jan. 6th, 2014
Good morning, Commissioner Rathgeber and Assistant General Counsel, John Carter. Thank you for scheduling this second public hearing in response to my request for it. There remain a number of questions which TDI has yet to answer and the people deserve another opportunity to be heard on this important issue.
First, I want to be very clear about avoiding the political straw men in this this conversation.
Texans support common-sense requirements such as criminal background checks for navigators. The bill I authored in the legislative session allowing for navigator regulations prohibits convicted felons from providing these services. Of course the state should enforce that provision and protect consumers. We shouldn’t have electioneering; my bill prevents that too. And we need to be sure we protect privacy.
We are all in agreement that these requirements are paramount to protecting consumers – that’s why we put them in the bill.
But my bill authorizes TDI to create regulations that protect the state from bad actors without making it harder for navigators to do their jobs. Remember the purpose clause of SB 1795: the purpose of this chapter is to provide a state solution to ensure that Texans are able to find and apply for affordable health coverage under any federally run health benefit exchange, while helping consumers in this state.
Your goal is to help ensure that Texans are able to find and apply for affordable coverage under the federally run exchange. Remember, those in control of the capital have chosen not to have a Texas exchange, creating the need for SB 1795.
The vast majority of healthcare navigators, as you can see and have seen from the testimony you received on September 30, 2013 and most recently on December 20, are honest folks who are working hard, and in good faith, to connect their fellow Texans with health insurance.
TDI has yet to provide justification for why it has gone as far as it has with these rules.
On December 20, I and several other senators submitted a letter to you in which we requested explanations to very specific questions. The people of Texas deserve answers to these questions. They deserve to know why some of these proposed rules are so far-reaching.
What’s very troubling to me is that my office asked when we might expect answers to these questions. We were told that an email you sent on December 23 was a reply. But that so-called reply reads as an acknowledgement of receiving the letter – not as a response to it. In fact, you seem to suggest you will answer these questions in the final rule order. With all due respect, Commissioner, that’s inappropriate. As I stressed in my September 30 testimony to you, because this issue has been so politicized, people have reason—even an obligation to be skeptical. So process matters here.
Your process – your refusal to answer critical questions prior to the final rule order – leaves no opportunity to discuss fallacies or poor decisions before the proposed rules are final. More importantly, it robs Texans of a transparent, accountable process and avoids a fair debate on the issue.
So, what are the questions that haven’t been answered?
- TDI has yet to explain how it arrived at the arbitrary 40 hour training requirement, in addition to the 20-30 federally required training hours.
- Nor has TDI explained how it arrived at the 13-13-14 hours of training in the areas of Texas Medicaid, privacy and ethics, respectively.
- TDI has not explained why navigators will have to pay registration fees as well as significant costs associated with additional training in light of a) the fact that navigators cannot charge a fee for their service, and b) the fiscal note for SB 1795, based on information provided by TDI, assumes any cost associated with implementation of the bill would be absorbed with existing staff and resources.
- TDI has yet to explain how it arrived at the proposed options for proving financial responsibility, which include surety bonds.
- TDI has yet to provide a detailed timeline showing each step that a navigator organization and individual navigators must accomplish to come into compliance with the proposed rule. We also haven’t seen a timeframe for which each step can reasonably be completed — an essential question for honest, hard-working Texans who are working right now to connect folks with health insurance.
- TDI has not explained how extending the registration requirements to almost anyone providing enrollment assistance protects Texas consumers, or how restricting the use of the term navigator outside of the federally operated insurance exchange protects Texas consumers.
Under your proposed rules, navigators must comply with many of the rules’ requirements by March 1, 2014. Assuming this rule becomes effective in early February, navigators and navigator organizations will have only about a month to come into compliance.
Given that the open enrollment period for people seeking coverage in 2014 ends on March 31, I fear that many navigator entities will face significant problems in meeting your proposed rules without compromising their ability to help Texans secure health care. I respectfully request that you postpone the compliance deadline until after the open enrollment period ends.
And although the training requirements for TDI-certified courses are not applicable until May 1, 2014, I question how many companies will be able to set up the training and examination requirements precisely as you’ve laid out in the proposed rules. An open and transparent process shouldn’t result in a product that only a certain business or type of business can provide.
People have a right to question whether the timing, combined with the extremely expanded training requirement that doesn’t seem capable of justification other than because the Governor suggested it, might be to benefit a private provider of training. Perhaps one that already has a contract with the state. This would put public money that should be going to help people get health coverage in a private enterprise’s hands. Again, with no justification.
I respectfully request that you delay the implementation of the state training requirements until the universe of potential providers can be better assessed.
We still have time to do this right. You still have the opportunity to strike the appropriate balance between two equally important responsibilities: protecting consumers, and ensuring Texans have access to the health insurance that’s right for them.
I urge you to provide answers to the questions raised by members of the Senate on December 20 and to do so before you finalize this rule.
In Texas, the Republicans will consort with convicted felons to hoax up stories about people trained to help enroll Texans for health insurance, and make completely unsubstantiated claims that the helpful people are felons, and Texans should worry about it.
If the GOP will take the word of felons to impugn the Affordable Care Act, why are they worried about the honesty of others who are not known to be felons, on the other side?
If it doesn’t make your head hurt, you’re not paying attention.
Hey, the numbers are off only by a factor of 500.
Gotta give credit to the GOP propaganda machine to have gotten so many Americans so soundly disinformed and het up about such a small number, smaller than anyone expected.
Should this qualify as a hoax? If Obama had screwed up a number by 500, what would the headlines be?
Just sayin’, you know?
This is news economists and budget watchers and policy makers have been hoping to hear for 60 years.
Here it is — did you see it in your local paper? On TV? On Facebook?
One criticism aimed at the Affordable Care Act that had some legs was that it did not go far enough to control actual costs. Cost controls would have been impossible to add to the bill, politically. So the hope was that this first step would have some impact.
In 2009, health care cost inflation ran about 20% per year, despite the recession. For the previous two decades, health care costs inflated at a greater-than 10% clip every year.
By 2012, with a push from the reforms in the ACA, Bill Clinton reported that health care cost inflation had dropped to 4% per year.
Now? 1.3%. This is huge news.
Who covered it? Not many, according to ThinkProgress.
Bad news gets 24-hour coverage and bulletins during the ads. Good news is an orphan. How wrong is that?
Bookmark the chart and ThinkProgress; you’ll need facts in your discussions.
Description from PBS NewsHour:
Published on Jun 8, 2012
Health correspondent Betty Ann Bowser talks with Jonathan Gruber, the author of “Health Care Reform,” the comic book. The MIT economist and professor of economics hopes the graphic layout of his book will help more Americans understand the complex law and its implications.
Read more about Gruber’s book and the health care reform law on the NewsHour’s Health Page: http://www.pbs.org/newshour/topic/hea….
Be sure to see what’s going on more than a year later, in the immediately previous post, “Winners and losers.”
GOP panic spreads. But will they run the correct way in their panic, say to vote for a clean, 12-month continuing resolution and and a raise to $18 trillion in the debt ceiling?
ObamaCare working in Utah. Who would have imagined that? The Sherburnes seem happy with what they bought.
This comes up in discussions about ObamaCare all the time.
These guys at Vlog have it nailed pretty well. Don’t know much about ’em, but their facts square:
Vlog brothers wrote:
Published on Aug 20, 2013
In which John discusses the complicated reasons why the United States spends so much more on health care than any other country in the world, and along the way reveals some surprising information, including that Americans spend more of their tax dollars on public health care than people in Canada, the UK, or Australia. Who’s at fault? Insurance companies? Drug companies? Malpractice lawyers? Hospitals? Or is it more complicated than a simple blame game? (Hint: It’s that one.)
For a much more thorough examination of health care expenses in America, I recommend this series at The Incidental Economist: http://theincidentaleconomist.com/wor…
The Commonwealth Fund’s Study of Health Care Prices in the US: http://www.commonwealthfund.org/~/med…
Some of the stats in this video also come from this New York Times story: http://www.nytimes.com/2013/06/02/hea…
This is the first part in what will be a periodic series on health care costs and reforms leading up to the introduction of the Affordable Care Act, aka Obamacare, in 2014.
The other videos should be similarly enlightening, we hope.
Funny. They don’t complain about ObamaCare so much.
Watch the charts, get the facts. Obamacare is working well.
First, let’s look at the food service industry. Hoaxsters claim that restaurants are cutting hours of employees and refusing to hire, to avoid the law. Not so.
So food service establishments — restaurants — have experienced sales and employment growth as has the rest of the economy during the Obama administration. What about employees? Are restaurants cutting back their hours to avoid providing benefits to employees? Evidence suggests the opposite: Hours worked per employee are increasing. Go to the chart:
During the four years since the recession ended in June 2009, 87% of the increase in employment has been due to a rise in the number of workers in full-time jobs. And looking at the period since ACA was signed in March 2010, more than 90% of the rise in employment has been due to workers in full-time jobs. Moreover, the length of the average workweek for private sector production and nonsupervisory employees has returned to its level at the start of the Great Recession.
And while the number of involuntary part-time workers has declined roughly in line with previous recoveries, it spiked up 322,000 in June. However, nearly 30 percent of the June increase was due to federal employees. This suggests that furloughs contributed to the pickup in part-time employment.
These observations strongly suggest that the Affordable Care Act has not constrained growth in hiring or work hours. So what is the ACA doing? It’s slowing the growth rate of health care costs for consumers, creating new incentives for providers to raise the quality of care, and adding new transparency and accountability in the insurance marketplace—all steps that help the economy.
ObamaCare is working — the Affordable Care Act has provided cheaper health care, much broader insurance coverage, better health — and seems to be stimulating industry, too.
A guy named William Duncan at a blog called Sensible Thoughts posted something I found inherently unsensible a while back. He listed six reasons why he thought the Affordable Care Act should be repealed. (“A while?” “Yeah, July 2012 is ‘a while.'”)
His sixth point was the old canard about Congress and the President being exempt. Of course they are not exempt, and so I told him.
Your sixth reason is in error. There is no provision to exempt either the president or Congress from the act. There is no language in the bill such as you describe. Language from page 114 can be found here:
At some length, Mr. Duncan removed that point, but said he still thinks the law should be repealed on the other five points I hadn’t dealt with.
Thank you for the correction on point #6. I have gone back and looked at this, and you are absolutely right. Although the Wall Street Journal and folks like Sean Hannity reported that the President and members of Congress are exempt from participation in the Affordable Care Act, in the end that did NOT make it into the language of the legislation. I have deleted point #6 from the post as a result. Thank you for the correction. Now, if you copuld only prove me wrong on the rest of the points listed…. Unfortunately, this remains a bill the the American public did not want, and was purchased by shenanigans that the Administration should be ashamed of.
A quick and dirty response; we may need to put more meat on these response bones in the next couple of months, because the opposition to ObamaCare relies on severely distorted claims about the law and what it actually does. Much if not most of the good stuff in the law is completely ignored by these critics, and we should point that out, too.
What makes you think Americans didn’t want it? There was a whale of an anti-health care campaign after the act passed, but when it passed, it enjoyed a majority of support. And, when we take each provision of the bill and ask people about that provision, they approve overwhelmingly.
For example, not even you are opposed to continuing the Reagan-era program that encourages medical schools to train more general practitioners. No one seriously objects to the provisions that pay physicians to practice in under-served areas, like West Texas, Iowa, and West Virginia. No one objects to the provisions that train more nurses. Only the most rabid racists complain about continuing and expanding the health care clinics on Indian reservations.
The law has dozens of provisions like those, and no one in their right mind objects to them.
Your other five points?
- The Supreme Court killed that one for you. They said that, even if you call it a fine, it’s a tax. And at that, it’s a helluva bargain. For those who do not purchase health insurance because they can’t afford to, they must pay $695 additional tax, per year. That’s about what I’d pay monthly on the open market.In any case, there are no fines, according to the Supreme Court.
But I can’t imagine why you oppose bargains in health care, especially when they lower the costs of health care to the insured, who will no longer pay the 15% to 25% premium to cover indigent care.
- With all the “new taxes,” CBO, the non-partisan group that scores these issues for Congress, projects the bill will decrease federal spending and cut the deficits annually, when fully enacted in 2014 and all out years.Do you oppose deficits or not?All the other taxes are fair, strike only the tippy-top income tiers, and are cheap at that.These taxes make the system more fair. It’s stacked against anyone making less than $150,000 a year, now. That’s most of us. I don’t like it when government helps the rich, at the expense of the poor — that’s contrary to moral standards my church holds, for example, and it tends to damage the economy.So I think more fair taxes, and lower costs, will be quite popular, once we see them.So, new taxes aren’t a good justification to oppose the law.
- Speaking of fallacious accounting — CBO, the group you cite, says the bill will reduce the deficits. You assume the Law won’t work, while small portions of it have already slashed inflation in health care costs, from 20% in 2009 to 4% in 2011 and 2012.But, what about repeal? CBO looked at that, too — repeal of the law will increase deficits, not decrease them. It’s only $109 billion increase in deficits, but these number directly refute all claims that repeal would be cheaper. See the analysis gateway here: http://www.cbo.gov/publication/43471
- This Medicare issue was hashed out, accurately and well I thought, in the campaign. Medicare costs will be reduced by holding costs down — benefits will not be reduced. Eric Cantor and Paul Ryan ran into some difficulty with this, because their budget plans assumed the savings from the Affordable Care Act, while eliminating the law that produced the savings.I’m sure there will be some adjustments required. Medicare seems a little ham-fisted when it comes to dealing with local and regional cost differences, but nationwide, over the past 40 years, enormous savings have been realized by reducing some reimbursements for procedures that once were uncommon and expensive, to a less expensive rate, now that they are more common. On the whole, over 40 years, over thousands of procedures, physicians have changed their expectations, and things have worked fine. Oh, there have been grumblings, I know. But the cuts in costs, without cuts in benefits, have stuck.Under the Affordable Care Act, we hope a lot more people will move to company plans from Medicare, or at least to the exchange plans offered in each state.One of the changes already introduced is working [link added here]. Rather than pay providers for each procedure, Medicare now reimburses hospitals for effective hospitalization — that is, when a patient is discharged and then re-enters a hospital for the same complaint, the hospital will lose money. Hospitals are keeping patients a few days longer on many procedures, to insure that one hospitalization is all that is required. Savings are already being made in costs, while improvements have resulted in the health care – better health in the patients!In all, CBO says costs will come down with the Affordable Care Act, as advertised, and costs will rise and deficits will rise if the Act is repealed.
- Your abortion argument is too metaphysical, and not enough real-world. Do you want to reduce the number of abortions? Then provide health care, make sure contraception is freely available (not for free, but freely), and stand back. Those two things reduce abortions, as they did during the Clinton administration.Restrictions on abortion, on the other hand, make it more likely a woman will choose to terminate a pregnancy under a number of circumstances: She doesn’t have health care coverage, her coverage does not cover pre-natal care, her coverage won’t cover a new infant, the pregnancy is unplanned due to lack of good information on family planning or lack of access to affordable contraception.You can choose: Restrict abortions and increase the number of abortions, or provide health care, and reduce the number of abortions.It may be a bit counter-intuitive, but you’d better study the issue. The Affordable Care Act’s provisions, Obamacare, have over the years reduced abortions where applied; cutting off that care has increased the number of abortions.My advice would be, don’t kill the babies to make a political point.
I am concerned that you don’t appear much familiar with what the bill actually does. Here are a few reasons to keep the law.
- We need more physicians, and the bill provides them.
- We need more physicians in underserved areas, and the bill provides them.
- We need more nurses, and the bill provides them.
- We need more community clinics in underserved urban areas [link added here], where illnesses and injuries frequently go untreated until extreme trauma results, and the victim must get extremely expensive care in an emergency room. This will be one of the biggest cost savers — and the law provides those clinics.
- The law will cut the private bureaucracy, and completely dismantle the private death panels set up by insurance companies, saving at least 10% of every health care dollar, applying that money to care instead of bureaucracy. This is already occurring.
- Preventive care under the Act is greatly encouraged — if we can boost flu vaccines by another 10%, it will save thousands of lives annually, and millions of dollars in hospitalization costs. Flu shots came with no co-pay this year — did you notice? — so that anyone with any insurance at all could drop by any pharmacy offering flu shots and get one with no out-of-pocket expenses.
This is huge. Everyone agrees the cheapest health care is for healthy people. The Affordable Care Act changes the way health care is delivered, to emphasize prevention of disease and injury, instead of triage. Prevention usually costs about 10% what the triage would cost.
- Removing the lifetime cap on insurance payments, per patient, will save a few thousands of lives, annually. It should kill the phenomenon where many families, hit with a costly disease or accident, had to declare bankruptcy as a result. A significant portion of all bankruptcies have been “not adequately-insured” cases. Those should almost disappear.
- Allowing children to stay insured, on a parent’s plan, for those critical years after high school and college and into the second job, with benefits has already benefited millions of Americans, saving millions of dollars and probably a few lives.
I cannot imagine why anyone would want to go back to 20% annual health care cost inflation, the highest per capita health care costs in the world by a factor of two, while leaving one out of every seven people uninsured even though we were paying amounts more than the insurance would have cost.
Obamacare reduces the deficits, and puts our health system on the path to catch up to the rest of the industrialized world, with better care for less cost.
I’ll keep it, thank you.
(See this, too: “More good news about Obamacare: CBO says it will save money”
You almost can’t believe this is real. Boehner is the guy with the mustache, isn’t he?
You can read the entire decision here: http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf
5-4 decision, Chief Justice Roberts voting to uphold the bill, Kennedy voting against and leading the dissent.
Syllabus from the case (links added for your convenience, not in the original):
NATIONAL FEDERATION OF INDEPENDENT BUSINESS ET AL. v. SEBELIUS, SECRETARY OF
HEALTH AND HUMAN SERVICES, ET AL.
CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT
No. 11–393. Argued March 26, 27, 28, 2012—Decided June 28, 2012*
*Together with No. 11–398, Department of Health and Human Services et al. v. Florida et al., and No. 11–400, Florida et al. v. Department of Health and Human Services et al., also on certiorari to the same court.
In 2010, Congress enacted the Patient Protection and Affordable Care Act in order to increase the number of Americans covered by health insurance and decrease the cost of health care. One key provision is the individual mandate, which requires most Americans to maintain“minimum essential” health insurance coverage. 26 U. S. C. §5000A.For individuals who are not exempt, and who do not receive health insurance through an employer or government program, the means of satisfying the requirement is to purchase insurance from a private company. Beginning in 2014, those who do not comply with the mandate must make a “[s]hared responsibility payment” to the Federal Government. §5000A(b)(1). The Act provides that this “penalty”will be paid to the Internal Revenue Service with an individual’s taxes, and “shall be assessed and collected in the same manner” as tax penalties. §§5000A(c), (g)(1). Another key provision of the Act is the Medicaid expansion. The current Medicaid program offers federal funding to States to assist pregnant women, children, needy families, the blind, the elderly, and the disabled in obtaining medical care. 42 U. S. C. §1396d(a). The Affordable Care Act expands the scope of the Medicaid program and increases the number of individuals the States must cover. For example, the Act requires state programs to provide Medicaid coverage by 2014 to adults with incomes up to 133 percent of the federal poverty level, whereas many States now cover adults with children only if their income is considerably lower, and do not cover childless adults at all. §1396a(a)(10)(A)(i)(VIII). The Act increases federal funding to cover the States’ costs in expanding Medicaid coverage. §1396d(y)(1). But if a State does not comply with the Act’s new coverage requirements, it may lose not only the federal funding for those requirements, but all of its federal Medicaid funds. §1396c.
Twenty-six States, several individuals, and the National Federation of Independent Business brought suit in Federal District Court,challenging the constitutionality of the individual mandate and the Medicaid expansion. The Court of Appeals for the Eleventh Circuit upheld the Medicaid expansion as a valid exercise of Congress’s spending power, but concluded that Congress lacked authority to enact the individual mandate. Finding the mandate severable from the Act’s other provisions, the Eleventh Circuit left the rest of the Act intact.
Held: The judgment is affirmed in part and reversed in part.
648 F. 3d 1235, affirmed in part and reversed in part.
1. CHIEF JUSTICE ROBERTS delivered the opinion of the Court with respect to Part II, concluding that the Anti-Injunction Act does not bar this suit.
The Anti-Injunction Act provides that “no suit for the purpose of restraining the assessment or collection of any tax shall be maintained in any court by any person,” 26 U. S. C. §7421(a), so that those subject to a tax must first pay it and then sue for a refund. The present challenge seeks to restrain the collection of the shared responsibility payment from those who do not comply with the individual mandate. But Congress did not intend the payment to be treated as a “tax” for purposes of the Anti-Injunction Act. The Affordable Care Act describes the payment as a “penalty,” not a “tax.” That label cannot control whether the payment is a tax for purposes of the Constitution, but it does determine the application of the Anti-Injunction Act. The Anti-Injunction Act therefore does not bar this suit. Pp. 11–15.
(a) The Constitution grants Congress the power to “regulate Commerce.” Art. I, §8, cl. 3 (emphasis added). The power to regulate commerce presupposes the existence of commercial activity to be regulated. This Court’s precedent reflects this understanding: As expansive as this Court’s cases construing the scope of the commerce power have been, they uniformly describe the power as reaching “activity.” E.g., United States v. Lopez, 514 U. S. 549, 560. The individual mandate, however, does not regulate existing commercial activity. It instead compels individuals to become active in commerce by purchasing a product, on the ground that their failure to do so affects commerce.
Construing the Commerce Clause to permit Congress to regulate individuals precisely because they are doing nothing would open a new and potentially vast domain to congressional authority. Congress already possesses expansive power to regulate what people do. Upholding the Affordable Care Act under the Commerce Clause would give Congress the same license to regulate what people do not do. The Framers knew the difference between doing something and doing nothing. They gave Congress the power to regulate commerce, not to compel it. Ignoring that distinction would undermine the principle that the Federal Government is a government of limited and enumerated powers. The individual mandate thus cannot be sustained under Congress’s power to “regulate Commerce.” Pp. 16–27.
(b) Nor can the individual mandate be sustained under the Necessary and Proper Clause as an integral part of the Affordable Care Act’s other reforms. Each of this Court’s prior cases upholding laws under that Clause involved exercises of authority derivative of, and in service to, a granted power. E.g., United States v. Comstock, 560 U.S. ___. The individual mandate, by contrast, vests Congress with the extraordinary ability to create the necessary predicate to the exercise of an enumerated power and draw within its regulatory scope those who would otherwise be outside of it. Even if the individual mandate is “necessary” to the Affordable Care Act’s other reforms, such an expansion of federal power is not a “proper” means for making those reforms effective. Pp. 27–30.
3. CHIEF JUSTICE ROBERTS concluded in Part III–B that the individual mandate must be construed as imposing a tax on those who do not have health insurance, if such a construction is reasonable.
The most straightforward reading of the individual mandate is that it commands individuals to purchase insurance. But, for the reasons explained, the Commerce Clause does not give Congress that power.It is therefore necessary to turn to the Government’s alternative argument: that the mandate may be upheld as within Congress’s power to “lay and collect Taxes.” Art. I, §8, cl. 1. In pressing its taxing power argument, the Government asks the Court to view the mandate as imposing a tax on those who do not buy that product. Because “every reasonable construction must be resorted to, in order to save a statute from unconstitutionality,” Hooper v. California, 155 U. S. 648, 657, the question is whether it is “fairly possible” to interpret the mandate as imposing such a tax, Crowell v. Benson, 285 U. S. 22, 62. Pp. 31–32.
4. CHIEF JUSTICE ROBERTS delivered the opinion of the Court with respect to Part III–C, concluding that the individual mandate may be upheld as within Congress’s power under the Taxing Clause. Pp. 33–44.
(a) The Affordable Care Act describes the “[s]hared responsibility payment” as a “penalty,” not a “tax.” That label is fatal to the application of the Anti-Injunction Act. It does not, however, control whether an exaction is within Congress’s power to tax. In answering that constitutional question, this Court follows a functional approach,“[d]isregarding the designation of the exaction, and viewing its substance and application.” United States v. Constantine, 296 U. S. 287,
294. Pp. 33–35.
(b) Such an analysis suggests that the shared responsibility payment may for constitutional purposes be considered a tax. The payment is not so high that there is really no choice but to buy health insurance; the payment is not limited to willful violations, as penalties for unlawful acts often are; and the payment is collected solely by the IRS through the normal means of taxation. Cf. Bailey v. Drexel Furniture Co., 259 U. S. 20, 36–37. None of this is to say that payment is not intended to induce the purchase of health insurance. But the mandate need not be read to declare that failing to do so is unlawful. Neither the Affordable Care Act nor any other law attaches negative legal consequences to not buying health insurance, beyond requiring a payment to the IRS. And Congress’s choice of language—stating that individuals “shall” obtain insurance or pay a “penalty”—does not require reading §5000A as punishing unlawful conduct. It may also be read as imposing a tax on those who go without insurance. See New York v. United States, 505 U. S. 144, 169–174. Pp. 35–40.
(c) Even if the mandate may reasonably be characterized as a tax, it must still comply with the Direct Tax Clause, which provides:“No Capitation, or other direct, Tax shall be laid, unless in Proportion to the Census or Enumeration herein before directed to be taken.” Art. I, §9, cl. 4. A tax on going without health insurance is not like a capitation or other direct tax under this Court’s precedents. It therefore need not be apportioned so that each State pays in proportion to its population. Pp. 40–41.
5. CHIEF JUSTICE ROBERTS, joined by JUSTICE BREYER and JUSTICE KAGAN, concluded in Part IV that the Medicaid expansion violates the Constitution by threatening States with the loss of their existing Medicaid funding if they decline to comply with the expansion. Pp. 45–58.
(a) The Spending Clause grants Congress the power “to pay the Debts and provide for the . . . general Welfare of the United States.” Art. I, §8, cl. 1. Congress may use this power to establish cooperative state-federal Spending Clause programs. The legitimacy of Spending Clause legislation, however, depends on whether a State voluntarily and knowingly accepts the terms of such programs. Pennhurst State School and Hospital v. Halderman, 451 U. S. 1, 17. “[T]he Constitution simply does not give Congress the authority to require the States to regulate.” New York v. United States, 505 U. S. 144, 178. When Congress threatens to terminate other grants as a means of pressuring the States to accept a Spending Clause program, the legislation runs counter to this Nation’s system of federalism. Cf. South Dakota v. Dole, 483 U. S. 203, 211. Pp. 45–51.
(b) Section 1396c gives the Secretary of Health and Human Services the authority to penalize States that choose not to participate in the Medicaid expansion by taking away their existing Medicaid funding. 42 U. S. C. §1396c. The threatened loss of over 10 percent of a State’s overall budget is economic dragooning that leaves the States with no real option but to acquiesce in the Medicaid expansion. The Government claims that the expansion is properly viewed as only a modification of the existing program, and that this modification is permissible because Congress reserved the “right to alter, amend, or repeal any provision” of Medicaid. §1304. But the expansion accomplishes a shift in kind, not merely degree. The original program was designed to cover medical services for particular categories of vulnerable individuals. Under the Affordable Care Act, Medicaid is transformed into a program to meet the health care needs of the entire nonelderly population with income below 133 percent of the poverty level. A State could hardly anticipate that Congress’s reservation of the right to “alter” or “amend” the Medicaid program included the power to transform it so dramatically. The Medicaid expansion thus violates the Constitution by threatening States with the loss of their existing Medicaid funding if they decline to comply with the expansion. Pp. 51–55.
(c) The constitutional violation is fully remedied by precluding the Secretary from applying §1396c to withdraw existing Medicaid funds for failure to comply with the requirements set out in the expansion. See §1303. The other provisions of the Affordable Care Act are not affected. Congress would have wanted the rest of the Act to stand, had it known that States would have a genuine choice whether to participate in the Medicaid expansion. Pp. 55–58.
6. JUSTICE GINSBURG, joined by JUSTICE SOTOMAYOR, is of the view that the Spending Clause does not preclude the Secretary from withholding Medicaid funds based on a State’s refusal to comply with the expanded Medicaid program. But given the majority view, she agrees with THE CHIEF JUSTICE’s conclusion in Part IV–B that the Medicaid Act’s severability clause, 42 U. S. C. §1303, determines the appropriate remedy. Because THE CHIEF JUSTICE finds the withholding—not the granting—of federal funds incompatible with the Spending Clause, Congress’ extension of Medicaid remains available to any State that affirms its willingness to participate. Even absent §1303’scommand, the Court would have no warrant to invalidate the funding offered by the Medicaid expansion, and surely no basis to tear down the ACA in its entirety. When a court confronts an unconstitutional statute, its endeavor must be to conserve, not destroy, the legislation. See, e.g., Ayotte v. Planned Parenthood of Northern New Eng., 546 U. S. 320, 328–330. Pp. 60–61.
Read the entire decision, and its dissents, for the authoritative view . . .
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