By Karen Pallarito
WEDNESDAY, June 27 (HealthDay News) -- The U.S. Supreme Court on Thursday is expected to hand down its ruling on the constitutionality of the Patient Protection and Affordable Care Act, the Obama administration's signature legislative achievement.
The law set in motion a series of reforms designed to extend health coverage to more than 30 million uninsured Americans. It seeks to accomplish these goals in several ways. More lower-income people will be allowed to enroll in Medicaid, while other uninsured individuals can buy coverage through new state health insurance exchanges. Some people who buy coverage may qualify for tax credits.
The 2010 law's most controversial component -- and one of the key targets of the Supreme Court's scrutiny -- requires almost all Americans to maintain health insurance coverage or pay a penalty.
The law also aims to improve the quality and efficiency of health care. For example, there are programs to improve care coordination and reduce fraud and abuse in Medicare, the government-run insurance program for older and disabled Americans.
A number of the law's most popular provisions are already in effect. For instance, parents in private insurance plans that offer dependent coverage can keep their adult children on the plan up to age 26. And most plans must cover preventive health screenings, such as mammograms and colonoscopies, at no out-of-pocket cost to the patient.
Core elements of the law -- such as expanding Medicaid, establishing the state health insurance exchanges and requiring people to have coverage or pay a penalty, known as the "individual mandate" -- aren't scheduled to take effect until 2014.
The high court could decide to uphold the law in its entirety, strike it down entirely, strip away key provisions, or delay a decision until after penalties for not having insurance are assessed. No matter how it rules, there's no sign that the torrid debate over the cost and delivery of health care in the United States will be put to rest.
A recent Harris Interactive/HealthDay poll found, for example, that most Americans agree that changes are needed to sustain Medicare, but few want to pay higher taxes or spend more out of their own wallets to prop up the financially ailing program.
"I think it's a safe bet that the health-care cost debate is going to persist," said Ilya Somin, an associate professor at George Mason University School of Law in Arlington, Va., who has written legal briefs challenging the individual mandate.
The crux of the court challenge
One of the key questions that the Supreme Court is being asked to address is whether the individual mandate is constitutional. Opponents of the provision, set to take effect in 2014, argue that Congress cannot force people to buy health insurance or tax them for failing to pay the penalty.
Another point of contention is whether the law can survive without the individual mandate. New protections in the Affordable Care Act ban insurers from denying anyone coverage because of pre-existing medical conditions or from inflating premiums based on a person's medical history. But the law's architects insist that it would be too costly to implement these reforms if only the sick bought insurance.
"Without that requirement, there's an incentive for people to wait and purchase coverage only after they need medical service," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, a Washington, D.C.-based trade association representing the health insurance industry.
Also at issue is the constitutionality of the law's Medicaid expansion. States, in exchange for additional federal funding, must cover nearly all non-Medicare-eligible adults at or below 133 percent of the federal poverty level. In 2012, the cutoffs are $14,856 for an individual and $30,657 for a family of four.
In the two years since its passage, the Affordable Care Act has been the target of multiple lawsuits, with a handful of cases working their way through the federal appellate court system.
In previous cases, the 6th Circuit Court of Appeals in Cincinnati and the D.C. Circuit Court of Appeals in Washington upheld the individual mandate. But the courts have not ruled in lockstep. The 11th Circuit in Atlanta found the mandate unconstitutional but allowed the rest of the law, including the Medicaid expansion, to stand.