Title: The Constitutionality of the Affordable Care Act: An Update | Journal of Ethics | American Medical Association
Headings: The Constitutionality of the Affordable Care Act: An Update
The Constitutionality of the Affordable Care Act: An Update
The Court’s Holding
The Aftermath of the Ruling
References
Author Information

Content: Individual mandate. The most legally and politically controversial aspect of the ACA, the individual mandate requires Americans to purchase health insurance or face a government penalty, with some exceptions—particularly for low-income individuals who cannot afford to buy insurance [3]. The individual mandate has been considered necessary to cover the cost of U.S. health care. Without a mandate, fewer healthy people would pay into the system to counterbalance the cost associated with care for the sick. The healthy, mostly younger people would be able to “free ride,“ purchasing health insurance only when they got sick, after paying little or nothing up front when their use of services was lower [4, 5]. States that challenged the ACA argued that the individual mandate was an overreach of Congress’s commerce clause powers, the government’s well-recognized (but not limitless) power to regulate certain economic activity that either occurs between states or substantially affects the states in the aggregate [6, 7]. The court reasoned that the commerce clause allows the government to regulate actions of those who participate in a market but not the inactions of those who choose not to participate in that market [8]. Without this distinction, the government could regulate practically anything. Justices analogized that, for example, persons with poor diets are pervasive and more costly to the health care system than the uninsured, yet it would be seen as a strong liberty breach for the government to mandate that citizens purchase only health food [8]. While the court rejected the claim that the individual mandate was within Congress’s commerce power, the mandate was found to be constitutional as a tax [9].