(CN) - A federal judge in Washington, D.C., dismissed a lawsuit against President Barack Obama's health care law, ruling that the financial burden to the economy caused by those without coverage justifies the reform. U.S. District Judge Gladys Kessler is the third judge to uphold the law; two other judges have found it unconstitutional and about a dozen other courts have dismissed challenges for lack of standing.
More than 45 million Americans were without health insurance in 2009, according to a December 2008 report from the Congressional Budget Office, which Judge Kessler cited in her ruling Tuesday.
The Patient Protection and Affordable Care Act began garnering passionate public interest well before it was signed into law last year, and has continued to be a contentious issue since its inception.
"The controversy surrounding this legislation is significant, as is the general public's interest in the substantive reforms contained in the act," Kessler's 64-page opinion states. "It is highly likely that a decision by the U.S. Supreme Court will be required to resolve the constitutional and statutory issues which have been raised."
As challenges to the law played out in federal courts across the nation, the Virginia attorney general asked the U.S. Supreme Court earlier this month to take up the case before the 4th Circuit can hear an appeal.
In December, U.S. District Judge Henry Hudson, a George W. Bush appointee presiding in Virginia, became the first federal judge to find that a provision of health care that requires most Americans to buy health insurance was unconstitutional. A month later, U.S. District Judge Roger Vinson, an appointee of President Ronald Reagan presiding in Florida, had trouble with the same provision, but found that the section could not be struck out to preserve the rest of the act.
Judge Kessler, a President Bill Clinton appointee, notes in her ruling that the taxpayers who sued the government in the case at hand have standing to sue, but that Congress has authority under the Commerce Clause to enact the individual mandate. The two other judges to uphold health care, in Michigan and a different district of Virginia, were also Clinton appointees.
The controversial individual mandate provision, which is set to take effect in 2014, imposes penalties on eligible citizens who choose not to purchase health insurance.
Five plaintiffs in this case claimed they could afford health insurance but have chosen not to buy it in the past and do not wish to in the future. They sought a declaration that Congress exceeded its constitutional powers when it passed the legislation.
Margaret Peggy Lee Mead, Charles Edward Lee, Susan Seven-Sky, Kenneth Ruffo and Gina Rodriguez protested that they should not have to make the "shared responsibility payment" to the government for refusing coverage.
Judge Kessler found that the condition of the national health care market "could not be clearer" in indicating that Congress had a rational basis for enacting the broad legislation.
"The great majority of the millions of Americans who remain uninsured consume medical services they cannot pay for, often resulting in personal bankruptcy," Judge Kessler wrote, noting a statistic in the act that 62 percent of all personal bankruptcies are caused in part by medical expenses.
"Of even greater significance to the national economy is the fact that these uninsured individuals are, in fact, shifting the uncompensated costs of those services - which totaled $43 billion in 2008 - onto other health care market participants, as well as federal and state governments and American taxpayers," the ruling states. "Because of this cost-shifting effect, the individual decision to forgo health insurance, when considered in the aggregate, leads to substantially higher insurance premiums for those other individuals who do obtain coverage.
"According to Congress, the uncompensated costs of caring for the uninsured are passed on by health care providers to private insurers, which in turn pass on the cost to purchasers of health insurance.
Judge Kessler quoted another statistic from the law that says cost-shifting increases family premiums by on average of over $1,000 a year.
The plaintiffs, who live in North Carolina, Texas and New York, had claimed present and future injuries arising from the Affordable Health Care Act.
"Plaintiffs strenuously object to the act's individual mandate because they believe that the federal government lacks the constitutional authority to require them either to purchase health insurance or pay a substantial penalty," the ruling states.
The court rebuffed both assertions, yet appeared more hesitant to stretch the bounds of the Commerce Clause.
"In undertaking this analysis, the court is mindful of the proper balance of power among the different branches of the federal government and, in particular, of its duty to apply a presumption of constitutionality when reviewing laws passed by Congress," Judge Kessler wrote. "At the same time, this court must also be mindful of the Supreme Court's consistent warning that the outer limits of the Commerce Clause must be respected, lest 'the distinction between what is national and what is local' be 'obliterate[d],' resulting in a completely centralized government."
In a footnote, the judge bolstered her position that Congress was justified in its efforts to stabilize prices and thwart such "market-distorting behavior" as choosing to remain without health coverage when it's available.
"To put it less analytically, and less charitably, those who choose - and plaintiffs have made a deliberate choice - not to purchase health insurance will benefit greatly when they become ill, as they surely will, from the free health care which must be provided in emergency rooms and hospitals to the sick and dying who show up on their doorstep," she wrote. "In short, those who choose not to purchase health insurance will ultimately get a 'free ride' on the backs of those Americans who have made responsible choices to provide for the illness we all must face at some point in our lives."
Read the Top 8
Sign up for the Top 8, a roundup of the day's top stories delivered directly to your inbox Monday through Friday.