What's Going on in the Courts with Health Care Reform? Part Two

Last updated: February 2011

In part one of this series I introduced the legal issues related to court challenges to the federal Patient Protection and Affordable Care Act (ACA) and specifically discussed the challenges regarding the individual mandate requirement. In this second part of the series I will share more details about the other three main legal issues: insurance market reforms, minimum employer contribution and Medicaid expansion.

The ACA is being challenged in federal courts across the country by states, legislators, nonprofit organizations and private citizens. At issue in the more than 20 cases that have been filed in federal district courts is whether the ACA violates the Constitution. This is relevant to Migraine.com readers because a variety of provisions will help migraineurs get access to health care services. One of the biggest changes is the elimination of pre-existing condition exclusions. As people living with the chronic health condition of migraines, the law will make it possible for us to get insurance coverage and make it easier for us to afford it.

Minimum Employer Contribution - Employers that do not provide insurance coverage for their employees are required to give a minimum financial contribution to their employees to help them pay for the cost of buying an insurance policy on the private market.

A number of states have challenged the ACA arguing that the minimum employer contribution requirement violates the Constitution by violating state sovereign immunity (protection against being sued for their actions). Their view is that states are employers and by requiring employers to follow this law the federal government is imposing on the states' right to handle their own affairs without being punished by the federal government for their decisions. In a 2000 case the Supreme Court said that a law that applies equally to private employers and states as employers does not violate the states' sovereign immunity.

In its lawsuit the private Liberty University argued this requirement exceeds Congressional authority to act under the Commerce Clause (the right of Congress to make laws that regulate commerce involving multiple states). The judge dismissed this claim. He said it is well-established that Congress has the right to regulate employment and employers and that health insurance clearly involves interstate commerce.

Insurance Market Reforms - The provisions of the law aimed at reforming the insurance industry are another issue raised in these legal challenges. These provisions require insurance companies to issue policies to people regardless of their health status and without charging higher premiums because a prospective customer's health issues.

The states that have sued have argued this portion of the law violates the Constitutional right of the states to exercise their police power. A 1945 federal law delegated the regulation of health insurance to the states, however, the 1996 Health Insurance Portability and Accountability Act (HIPAA) created an exception to that law to allow for federal regulation of health insurance.

These states also claim that forcing the states to enforce the federal requirements and maintain state exchanges violates their sovereign immunity. However, as the judge in the Florida case noted, states are not required to establish exchanges, so their sovereign immunity is not being violated.

Medicaid Expansion - States must expand their Medicaid programs to cover a wider range of low-income individuals.

States have initiated lawsuits challenging the authority of Congress to force them to cover these additional citizens. They argue the changes imposed by the ACA turn Medicaid from a voluntary program into a mandatory program for the states. In past cases the Supreme Court has said that participation in Medicaid is voluntary, but that once states decide to participate they must follow the program guidelines established by the federal government. While a Florida judge has allowed this argument to proceed for further consideration, it remains to be seen how the changes called for under the ACA differ from any other federal rules about Medicaid.


More of these cases are being heard each month and as more decisions are issued we will have an increasingly clear idea of the viability of these legal claims. Right now most of the claims are not successfully moving forward, but a few have found a sympathetic ear in court and won't be resolved quickly.

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This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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