Health Care Law Is Constitutional, Court Says

(CN) - The 6th Circuit on Wednesday affirmed the constitutionality of President Barack Obama's health care law - the first time a federal appeals court has ruled on the controversial overhaul.

Appeals stemming from passage of the Patient Protection and Affordable Care Act are currently pending in other federal appeals courts, including most notably in the 11th and 4th Circuits.

In October 2010, U.S. District Judge George Steeh of Detroit rejected a challenge to a provision of the act that requires most Americans to buy health insurance.

Following that decision, the Thomas More Law Center and four individuals sought relief from the Cincinnati-based federal appeals court.

A three-judge panel of the 6th Circuit ruled Wednesday that the minimum coverage provision, also labeled as the individual mandate, is a valid exercise of legislative power by Congress under the Commerce Clause.

The provision, which is set to take effect in 2014, imposes penalties on eligible citizens who choose not to purchase health insurance.

"The Act considered as a whole makes clear that Congress was concerned that individuals maintain minimum coverage not as an end in itself, but because of the economic implications on the broader health care market," Judge Boyce Martin wrote for the court. "Virtually everyone participates in the market for health care delivery, and they finance these services by either purchasing an insurance policy or by self-insuring. Through the practice of self-insuring, individuals make an assessment of their own risk and to what extent they must set aside funds or arrange their affairs to compensate for probable future health care needs. Thus, set against the Act's broader statutory scheme, the minimum coverage provision reveals itself as a regulation on the activity of participating in the national market for health care delivery, and specifically the activity of self-insuring for the cost of these services."

Since Congress has the power to regulate economic activity, and that is the ultimate goal of health care reform, the opponents failed to bring a challenge under the commerce clause of the Constitution, according to the 26-page ruling.

"Congress found that without the minimum coverage provision, the guaranteed issue and community rating provisions would increase existing incentives for individuals to delay purchasing health insurance until they need care," Martin wrote. "The legislative record demonstrated that the seven states that had enacted guaranteed issue reforms without minimum coverage provisions suffered detrimental effects to their insurance markets, such as escalating costs and insurance companies exiting the market."

The judges also rejected the Thomas Moore Law Center's claim that health care reform impermissibly regulates inactivity. After first dismissing the notion that the Constitution distinguishes between activity and inactivity, the ruling states that the challenged provision does any such thing.

"Furthermore, far from regulating inactivity, the minimum coverage provision regulates individuals who are, in the aggregate, active in the health care market," Martin wrote.

Try as the might, most Americans are active in the health care market, the ruling states.

"Virtually everyone will need health care services at some point, including, in the aggregate, those without health insurance," Martin wrote. "Even dramatic attempts to protect one's health and minimize the need for health care will not always be successful, and the health care market is characterized by unpredictable and unavoidable needs for care. The ubiquity and unpredictability of the need for medical care is born out by the statistics."

More than 80 percent of adults nationwide visited a doctor or other health care professional one or more times in 2009, according to statistics from the Centers for Disease Control and Prevention quoted in the ruling.

And since federal law requires medical practitioners to treat all patients regardless of whether they can afford the treatment, it is a virtual certainty "that all individuals will require and receive health care at some point," Martin wrote.

"Thus, although there is no firm, constitutional bar that prohibits Congress from placing regulations on what could be described as inactivity, even if there were it would not impact this case due to the unique aspects of health care that make all individuals active in this market," the ruling states.

Resolving the appeal under the commerce clause, Martin added that the panel did not need to address whether the provision constitutes proper exercise of Congress's power to tax and spend under the general welfare clause.

Judge Jeffrey Sutton elaborated on the case in a separate 24-page opinion concurring in part and delivering part of the court's opinion.

"That brings me to the lingering intuition - shared by most Americans, I suspect - that Congress should not be able to compel citizens to buy products they do not want," Sutton wrote. "If Congress can require Americans to buy medical insurance today, what of tomorrow? Could it compel individuals to buy health care itself in the form of an annual check-up or for that matter a health-club membership? ... And if Congress can do this in the healthcare field, what of other fields of commerce and other products?

"These are good questions, but there are some answers. In most respects, a mandate to purchase health insurance does not parallel these other settings or markets. Regulating how citizens pay for what they already receive (health care), never quite know when they will need, and in the case of severe illnesses or emergencies generally will not be able to afford, has few (if any) parallels in modern life. Not every intrusive law is an unconstitutionally intrusive law. And even the most powerful intuition about the meaning of the Constitution must be matched with a textual and enforceable theory of constitutional limits, and the activity/inactivity dichotomy does not work with respect to health insurance in many settings, if any of them."

Sutton goes on to note that few question the authority of states to require its residents to have insurance, and such laws are already on the books in Massachusetts and New Jersey.

"Today's debate about the individual mandate is just as stirring, no less essential to the appropriate role of the National Government and no less capable of political resolution," Sutton concluded. "Time assuredly will bring to light the policy strengths and weaknesses of using the individual mandate as part of this national legislation, allowing the peoples' political representatives, rather than their judges, to have the primary say over its utility."

Senior U.S. District Judge James Graham, sitting on the panel by designation from the Southern District of Ohio in Columbus, concurred and dissented in part.

"If the exercise of power is allowed and the mandate upheld, it is difficult to see what the limits on Congress's Commerce Clause authority would be," Graham wrote. "What aspect of human activity would escape federal power? ... Such a power feels very much like the general police power that the Tenth Amendment reserves to the States and the people. A structural shift of that magnitude can be accomplished legitimately only through constitutional amendment."

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