WASHINGTON — Chief Justice John Roberts made clear in his opinion upholding most of the new health care law that the ultimate fate of the new law would not be determined by the nine justices of the Supreme Court.
Instead, Roberts was blunt: Policy decisions “are entrusted to our nation’s elected leaders, who can be thrown out of office if the people disagree with them.
“It is not our job to protect the people from the consequences of their political choices.” In doing so, Roberts made the November elections a clear choice. Vote for President Barack Obama to retain the law or vote for Republican presidential nominee Mitt Romney to strike it down. In other words: Voters, it’s in your hands. What that means now is a matter of debate.
“I think it’s good for Republican chances of taking the Senate and for Mitt Romney taking the presidency,’’ said Rep. Pat Tiberi, R-Genoa Twp. “I think it’s good politics for Republicans, bad politics for the president.’’
But Judith Feder, a professor of public policy at Georgetown University, said that “it remains to be seen how this will play as an electoral issue.’’
Although conservative Republicans were politically energized by the decision, she said if that energy “diminishes, as I hope it will, and President Obama is re-elected, as I hope he will be, we can move forward assertively’’ to implement the new law.
Still, voters will decide what to do with a very different law than the one Obama signed in 2010. For one thing, the law’s ambitious goal was to extend health coverage to 32 million of the 46 million Americans now without insurance. The court’s ruling effectively ensured that that goal would not be met.
For example, the law was to provide coverage to 16 million additional people by expanding Medicaid — a program jointly paid for by the federal and state governments.
During the first few years of the expansion, the federal government would pay 100 percent of the additional Medicaid costs to the states.
After that, the federal share would gradually drop to 90 percent.
Along with the carrot, the federal government also initially offered the following stick: Any state refusing to expand eligibility could see the federal government withhold its share of all Medicaid contributions to that state.
But the court struck that down, with Roberts and six other justices ruling that the federal government did not have the right to punish a state by withholding its entire Medicaid contribution. States such as Ohio, which faced the possibility of increasing Medicaid costs, can now refuse to adopt the new Medicaid eligibility standards without any punishment. It’s unclear whether they — and other states — will do so.
“Because half of the expanded coverage was coming through Medicaid, there is now a lot of uncertainty about how many states will move forward,’’ said Kenneth Thorpe, a professor of health policy management at Emory University in Atlanta. “There is going to be a substantial number of people remaining uninsured.’’
Feder is less certain that states such as Ohio will simply refuse to take part.
“There’s too much money on the table to say that,’’ she said.
“They’d be denying themselves, not to mention denying care to millions of Ohioans. My belief is that most of the states will find this is too good a deal to pass up.”
The law was also expected to provide coverage to another 16 million by providing federal subsidies to help a family of four earning as much as $88,000 a year to buy a private policy. But it required people to buy the insurance or face a fine.
Roberts modified that, ruling that while Congress could constitutionally tax people who do not buy insurance, it could not force them to buy what is essentially a private consumer product.
While that may not necessarily lead to fewer people being insured, Republicans are wielding it as a political club, arguing that Democrats – including Sen. Sherrod Brown of Ohio, who is up for re-election this year – voted to increase taxes on the middle class.
In a conference call with reporters Friday, Brown insisted that “it’s a fee on people who are free riders – people that have the money and can afford insurance, don’t get insurance, they go to the emergency room with an illness and we all pay for it.’’
“It’s no tax increase,’’ Brown said. “It’s no major thing that hits a lot of people. As Governor Romney knows from what they did in Massachusetts, very few people paid that fee because they got insurance.’’
Democrats cited a new Senate Finance Committee report that claims that for those Americans who use subsidies to buy insurance, it will actually result in a net savings.
More provisions in ’14
Should Obama win re-election and the law remains intact, by 2014 a number of the law’s provisions go into effect – including the more generous Medicaid standards, the requirement that companies with 50 or more workers provide their employees with access to a qualified plan, and the tax credits will become available for middle-income people wanting to buy a policy.
By 2018, a new tax will be levied on expensive insurance plans, those costing more than $10,200 for an individual and more than $27,500 for a family.
Insurers will be barred from rejecting people who are dealing with pre-existing conditions, and insurers will also be barred from charging more to people with medical problems.
Health insurers will no longer be able to impose annual dollar limits on the amount of coverage an individual may receive.
States will be required to create state-based insurance markets in order to help individuals and small businesses find affordable health coverage.
Already, Americans have seen the impact of the new bill: It has eliminated co-payments for preventive care and allowed young adults to stay on their parents’ insurance plans until they’re 26, for example.
Tom Miller, a resident fellow at the conservative American Enterprise Institute, said even though “the main show is over,” there’s still the possibility of small legal fights that will effectively erode some of those provisions. There’s also the possibility — if Republicans win the “triple crown” of the House, Senate and White House this November – that they’ll “debone and fillet” away other provisions of the bill, even if they don’t follow through on the promised repeal.
“This just doesn’t roll along no matter how hard you try,” he said.
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