Why has the Supreme Court Upheld the Affordable Care Act?

Sorry, in advance, for the length.

The PPACA (a.k.a. Obamacare) is not good for ALL Americans, but it is arguably good for most Americans. With just about any law, you will have winners and losers. The winners will be happy, and the losers will complain. The politicians on both sides will play on those gains and losses. With setting aside the political background, and the implications for recent and future elections, here's my take on the law.

The PPACA was a health reform policy that was based on conservative principles, and was designed to tweak the current health system, rather than blowing it up and implementing something radical (like a single-payer system, or a socialized healthcare system, or similar). The law was based on a few simple rules. First, everyone has to take responsibility for their own healthcare by getting their own insurance policy. Conceptually, the individual responsibility was not problematic. Operationally, the problematic component was the mandate that forced everyone to get a policy. Some people just don't like being told what to do, even if they know they should be doing it. Per the individual mandate, some people would buy coverage on their own (in the individual market), whereas others would get coverage through their employers (in the group market). Second, the law set up marketplaces/exchanges to allow people to comparison shop for insurance. Rather than separately contacting insurance company after insurance company, spending time and energy shopping around for the best policy, people would go to one place, and insurance companies would compete there. This component was also not that problematic. The law allowed states the flexibility to implement their own exchange (local control) or to have the Federal government implement an exchange on their behalf. Third, and arguably the most controversial component, was the recognition that some people wouldn't be able to afford healthcare. Thus, the Federal Government set up subsidies to help people afford health insurance. So, an individual mandate, reformed exchanges, and subsidies (or premium support, or whatever term you want to use) were all components of the original health reform plan proposed by the Heritage Foundation a generation ago. It was also the basis for Romneycare up in Massachusetts.

From that basic idea, the Federal Government added some additional components that remain controversial to this day. First, the law implemented a number of payment systems designed to reward quality of care, rather than quantity of care. Under the old system, if I went to the hospital, they got paid. If the hospital messed me up (say, I became wrongfully infected during my stay), and I had to return to the hospital, they got paid again (and so on). Under the new rules, they wouldn't get paid for those types of preventable readmissions, thereby giving them an incentive to improve the quality of care they provide. The law also shifted payment systems towards proactively keeping people healthy, rather than rewarding the delivery of services after someone becomes sick/injured. Prevention and wellness became much more important. The law even set up a preventive health fund aimed at improving prevention and wellness. It has become a political hot potato called an "Obamacare slush fund". Another issue involved the Federal Government recognizing that they couldn't provide subsidies to the very poor (who had no jobs to pay for any portion of their insurance policies), so they chose to expand Medicaid to cover them. The initial SCOTUS ruling in 2012 found this mandate to the States to be unconstitutional, so many States backed out (mostly citing an expectation of future costs). The Federal Government also standardized the services covered under the health insurance policies in order to force insurance companies to compete on price. Up until that point, the insurance companies didn't need to compete on price because they created customized policies for everyone, and you couldn't comparison shop because all of the policies were somewhat different (apples-to-oranges comparisons). That's why you hear people complain by saying things like "I'm a guy; I shouldn't have to pay for birth control coverage." That standardization is meant to bring down prices. Take away the standardization, and you lose the mechanism to force price competition. The Federal Government also mandated that people couldn't be excluded from policies due to pre-existing conditions. This component has pretty high public support, even to this day. The Federal Government also mandated that kids could remain on their parents' policies until 26 (presumably to get them through college and into the work force before the individual mandate kicked in for them). This component also remains fairly popular. The law also established a board whose goal was to find ways to reduce overall costs for healthcare (some politicians called them the "death panel"). The law also taxed medical device companies as a means to help pay for the subsidies. This tax has some bipartisan support for repeal. The law also moved money from Medicare to help pay for the subsidies. This was a controversial component that was played up big-time in the 2012 elections. The story there is that when a hospital sees a Medicare patient, Medicare pays the hospital a fee for that service, and the fee includes a component based on the amount of charity care the hospital provides (FYI, they also pay a fee for hospitals who are involved in graduate medical education). So, since under Obamacare you would have less uninsured (due to the individual mandate), the charity care reimbursements would decline. Since the reimbursements would decline, this source of funding would no longer be needed under Medicare, and would therefore be freed up to help people afford the insurance policies (via the subsidies). This "He/She stole from Medicare to pay for Obamacare" argument played rather well politically in a few places, but people who understood the linkage between the funding and the rate of uninsured knew that this was no big deal. The law has a number of other smaller components (after all, it is 2,000 pages long), but those are the big ones that stick out. Hope this helps.

With all of that being said, the U.S. health system needed to change. We had increasing health costs, increasing numbers of uninsured, and declining health standing (relative to other developed countries). This law certainly wasn't perfect, but it was better than the status quo. In the absence of a perfect alternative, or any alternative for that matter, the law was passed and went into effect. So, the ball is really in the GOP's court right now. They can come up with a viable alternative, sell it to the American people, and win elections on it (and then implement it). Or, they can work with the Democrats to improve the PPACA. Simply repealing it without an alternative basically implies that they prefer the old system. I'm not a big fan of the PPACA, but it's better than going back to the past.

From what I gather the Supreme Court ruled on the intent of the law rather than the specific wording of it. If the law was intended to restrict subsidies to only people on state run exchanges then it would have spelled it out clearly rather than a single phrase in the entire document. If the supreme court had ruled that they weren't allowed millions would have lost subsidies and been unable to afford insurance and the ACA would have self imploded. The only way it could have been fixed is if congress changed the wording which wouldn't have happened with a Republican congress or if the 34 states (most of which are red) that don't have an exchange started one.

The current ruling is in regards to Tax Subsidies as they apply to State Setup Exchanges vs Federal Setup Exchanges.

The "Letter" of the Law says that Tax Subsidies can only be applied to State Setup Exchanges (I believe there are 16). That excludes Federal Setup Exchanges (34 remaining).

The argument (for this ruling and ONLY this ruling) is whether the "Intent" or "Spirit" of the Law (Congress' Intent) was to Exclude those who live in States that did not set up State Setup Exchanges. If they had said Congress' Intent was to EXCLUDE, that would have REMOVED Taxed Subsidies, basically "unraveling" the PPACA.

The Ruling (6/3) was that Congress would not have Intended to create a law that excluded Federal Setup Exchanges. In essence, the Letter created oversights in "verbiage," which created the Legal Argument.

All of this said, though I disagree with the Law itself, the Ruling (Interpretation) seems most correct, as the question is "Would Congress have intended the Law to unravel if this provision was followed to the Letter?" As mentioned in another thread, I cannot in good faith say yes to that question, no matter how much I dislike this law.