Marquette University Law School Faculty Blog

If Milwaukee is to become a healthy city in both broad terms and in terms of specific issues, it must deal with issues in an honest, constructive way with poverty and race, City of Milwaukee Health Commission Bevan Baker said Thursday during an “On the Issues with Mike Gousha” session at Eckstein Hall.

“Milwaukee will not be the greatest, most relevant, healthiest city in America until we deal with our dirty linen,” Baker, health commissioner since 2004, told an audience of about 150.

“To do that,” he continued, “we have got to do what other cities have done, and that is to address race, to address poverty, to look at these issues, and say, it is tough, it is unimaginable, it makes me sick, it is ugly, but to be great we have got to do the unimaginable thing, and that is to once and for all say, and in true fashion, to take our spiritual and moral compass and say, Milwaukee will not be the healthiest, greatest, most relevant city in America until we deal with our dirty linen. That’s what New York has done and that is what Miami is trying to do and that’s what other cities in this nation I have lived in have done.” Read more »

Friday’s deadline, November 16, calls for each state, including Wisconsin, to give the federal government a “blueprint” for a Health Information Exchange.  State exchanges compare the benefits and costs of insurance policies and post the results online so people and employers can choose which are the best values for them.  They will also make electronic patient records accessible for treatment and research for the public health.   As I noted in my election-eve blog post, exchanges (also called HIEs) are central to health care reform by making better consumer choices possible.

State blueprints would resolve such choices as whether the exchange will be a private non-profit company or a state agency, and what consent and protections are in place for patient privacy.  Overall, a state can choose whether its exchange will be run by the state, in a partnership with the federal government, or by the federal government.  If a state doesn’t provide a blueprint, its exchange will be formed and run according the rules and models in federal regulations that will be issued soon.  Read more »

A good question posed: What really happens to healthcare when the election dust settles? The continued implementation or the repeal of Obamacare, the Affordable Care Act, is proposed as a difference that turns on the tally of the votes for president for 2013 to 2017. I think the answer is yes, but for reasons not included in the rhetoric of party platforms.

The chances of outright repeal are slim to none, because the math doesn’t work. The votes for repeal have split along party lines. The House with its Republican majority has voted repeatedly for repeal but can’t effect it. The votes needed must be found in the Senate. A supermajority of 60 out of 100 senators is needed to repeal a law. There are 47 Republican senators, and 51 Democrats plus two independents with Democratic-leaning views. Thirty-three seats are at issue in the election and a Republican majority is possible, but a change of views by voters will not produce sixty Republican-leaning senators.

A procedural option theoretically can reduce the votes needed for repeal to 51, an ordinary majority.   Read more »

I wrote here last March 26 about the issues of the anticipated Supreme Court opinion on the Affordable Care Act (ACA). Around the time the decision was announced, it seemed redundant to comment when a barrage of words — first, predictive punditry, then, delight, outrage, and more punditry about the “real” future of U.S. Health care – poured from every news outlet and policy shop that exists to examine the health care industry and its regulation.

In August 2012, implementation is underway, complex and sometimes perplexing. And many problems are not addressed at all.

To recap: On June 28, 2012, the Supreme Court announced its rulings on the constitutionality of the ACA. Most provisions of the law, including the individual mandate, were upheld. One important provision, requiring states to adopt the Medicaid expansion, was struck down. States could refuse to expand their Medicaid benefits and still receive federal funds that` pay at least 50% of the cost of their existing health care program for the poor. Several states have refused the expansion, although the federal government provides 100% of costs until 2020. The objective justification is that such a federal “hook” is eventually reduced, other incremental expansion is likely to follow, and once states begin to accept the funds it is virtually impossible, politically and practically, to stop.

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Immediately after learning that Chief Justice John Roberts had cast the deciding vote to uphold the Affordable Care Act’s individual mandate, I emailed my colleague Scott Idleman and suggested that Roberts was trying to be the new Charles Evans Hughes.

The reference, of course, was to Chief Justice Hughes who presided over the United States Supreme Court from 1930 to 1941. During the critical years of the early and mid-1930’s Hughes and his moderate Republican colleague Owen Roberts frequently sided with the Court’s three-man liberal bloc to uphold the constitutionality of a variety of relief statutes enacted to mitigate the harsh effects of the Great Depression. In doing so, Hughes frequently engaged in imaginative readings of supposedly settled parts of the Constitution, like the Obligations of Contracts Clause, the Due Process Clause of the Fourteenth Amendment, and the Commerce Clause.

I was not the only one to make the Hughes connection. The next day, my friend Dan Ernst of Georgetown University made a similar observation on the Legal History Blog.

However, I have come to believe that the better comparison for Chief Justice Roberts ’ Obamacare decision are the opinions of his legendary predecessor, Chief Justice John Marshall.

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The Supreme Court’s decision upholding the constitutionality of the Affordable Care Act has generated a great deal of “instant analysis” on the web.  This post will survey some of the noteworthy commentary.

I have not read anything that has caused me to re-evaluate my initial reaction to the decision.  I thought that neither Justice Robert’s Commerce Clause analysis nor his Taxing Power analysis was particularly compelling, yet I was struck by the manner in which the Chief Justice managed to construct a 5-4 majority that paralleled Marbury v. Madison insofar as the ruling chastized a sitting President with its rhetoric while simultaneously handing the President a major policy victory.  Upon further reflection, I still believe that future Supreme Court justices will find it quite easy to evade the boundaries that the language of the NFIB v. Sebelius decision purports to place on federal government power.  All it will take is a change in one vote for a future Court to designate the opinion’s Commerce Clause analysis as “dicta,” or else to find the requisite level of coercion lacking the next time that Congress’ deploys its Spending Power in a similar fashion.  While the rhetoric of the opinion promises doctrinal limits on federal power, the actual holdings of the decision fail to deliver on that promise.

John Yoo has come to the same conclusion.  In an op ed piece in the Wall Street Journal he considers the spin that some political conservatives have placed on the Court’s ruling — that it was a victory for the advocates of limited governent — and finds these assertions to be no more than a ”hollow hope.”  He rejects the comparison to Marbury v. Madison, and instead compares the opinion of Justice Roberts to the “switch in time” that led the Supreme Court to uphold New Deal Era legislation during the Franklin Roosevelt Administration.  By frustrating the Supreme Court’s best chance since the 1930s to reverse what Yoo views as an anti-originalist acceptance of broad legislative power, Justice Roberts has let Professor Yoo down. Read more »

The decision in National Federation of Independent Business v. Sebelius is a victory for the supporters of the Affordable Care Act, and a fairly broad vindication for the constitutionality of the law.  Here are my initial thoughts:

This is a big win for the Obama Administration.  The only portion of the law struck down is the Medicaid expansion provision, on the grounds that Congress cannot threaten to take away funds previously granted to the States if the States fail to accept new conditions.  This strikes me as a fairly reasonable gloss on the case of South Dakota v. Dole and, at the same time, a constitutional interpretation that still allows Congress a fair amount of flexibility to attach conditions to the receipt of new federal dollars.

I am not persuaded by Justice Robert’s argument rejecting Congress’ power under the Commerce Clause.  It strikes me as primarily conclusory rather than analytical, and my initial reaction is that it should be considered dicta since Justice Roberts upholds the ACA on other grounds.  Of course, I have already made clear that I am inclined to agree with Justice Ginsburg that the Court’s precedent under the Commerce Clause provides ample support for the ACA’s constitutionality, as I argued in previous posts here and here.

Nor am I convinced by Robert’s tax argument.  He labors a great deal to make the case that the ACA does not impose a “tax” for purposes of the statutory Ant-Injunction Act but nonetheless imposes a “tax” under Congress’ constitutional taxing authority.

It appears to me that Roberts tried to split the baby in a statesman-like way, by giving victory to Obama but by using reasoning and language designed to placate President Obama’s critics.  Am I the only person who read Justice Robert’s opinion and thought of Marbury v. Madison?

Today I particpated in another debate over the constitutionality of the Affordable Care Act’s individual mandate.  At the invitation of the Milwaukee Chapters of the Federalist Society and the American Constitution Society, I debated Robert Levy of the Cato Institute over luncheon at the Milwaukee Athletic Club.  My thanks to our hosts, to Mr. Levy, and to the audience.  Below are my prepared remarks.  My previous post on the consitutionality of the individual mandate can be viewed here.

In December 1783, George Washington gave a toast at a dinner celebrating the formal dissolution of the Revolutionary Army.  He did not use his toast to offer a tribute to individual liberty.  Nor did he sing the praises of limited government.  Instead, his toast was a simple expression of what he hoped the future would bring to our new nation. He raised his glass and he said: “Competent powers to Congress for general purposes.”

We must never forget that our Constitution is a document that was intended to create competent powers for Congress for general purposes.

Much of what Mr. Levy cites in oppostion to the individual mandate is based upon abstract principles.  However, when we interpret the Constitution, we do not begin with abstract theories of political philosophy, and then attempt to shoehorn those theories into the text.

Instead, when we interpret the Constitution, we begin by looking to the text itself.

The power to “regulate,” which is the power delegated to Congress under the Commerce Clause, is the power to prescribe the rules by which commerce is governed.  The word “regulate” means “to direct” or “to command.”  Therefore, the plain meaning of the word “regulate” in the text includes a grant to Congress of the power to require action. Read more »

The Court’s decision on the severability of the individual mandate may be the aspect of the PPACA litigation that is most difficult to predict. If the Court holds that the individual mandate is constitutional, then severability won’t be an issue in the first place. If severability does arise, whether and how the Court will sever the mandate is unclear. In part, this is because of problems with severability doctrine itself. Notwithstanding over a century of cases on the issue, the Court has had a hard time settling upon a definitive severability test. Sometimes the emphasis has been on legislative intent. Other times the focus has been on whether the constitutional remainder can function without the invalid part. Still other times the Court has severed or refused to sever without acknowledging the doctrine at all. The oral argument on severability reflected this state of affairs, as the Justices spent a considerable amount of time exploring the merits of several possible tests. Without knowing the doctrine, it is difficult to anticipate a result.

In part, the unpredictability also reflects the absence of a completely satisfying way to sever the mandate if it is unconstitutional. Because the PPACA lacks a severability clause, covers such a diversity of topics, and reflects a variety of legislative compromises, it is hard to identify a clear legislative intent with respect to severability. Because the invalidation of the mandate will render certain aspects of the core health-care reforms financially problematic, it is unsatisfying to focus exclusively on the textual separability of the mandate from surrounding provisions. And because courts are poorly equipped to appreciate the complexities of health care policy, it seems problematic to base severability on anticipated financial implications.

That being said, I think we can reasonably make a couple of predictions about this aspect of the decision. First, if the Court holds that the individual mandate is not severable, that holding will rest on the votes of the conservative Justices, who generally seemed much more skeptical of severability than their counterparts during oral argument. Read more »

Last week, Ed Fallone posted his prepared remarks at our debate on the constitutionality of the individual mandate in the health care law. Inspired by his example, I have – after a fashion – cleaned up my notes for last week’s debate. This is how I see it.

When Nancy Pelosi was asked about the potential for a constitutional challenge to the health care law, her response was “you’ve got to be kidding.” The substance of her response – “look, we used the commerce power and that permits us to do almost whatever we want” – reflected large patches of conventional wisdom.

Many lawyers (particularly those trained before the Rehnquist Court began to push back against an unlimited commerce power) and, in particular, Progressive legal academics thought that this dragon had been slain long ago. They assumed that the idea that there might be structural limits on the federal constitution had been relegated to the status of flat earth creationism and alchemy.

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This afternoon, I participated in a debate with Rick Esenberg at the Marquette University Law School.  The debate was co-sponsored by the American Constitution Society and the Federalist Society.  I was asked to defend the constitutionality of the individual mandate imposed by the Affordable Care Act.  What follows are my prepared remarks.

Historians tell us that the connection between access to health insurance and employment was an accident. During World War II, wage and price controls prevented employers from increasing cash compensation for their workers. Employers wishing to recruit workers began to offer subsidized health insurance benefits as a way of avoiding this freeze on wages.

This is not a gift to workers from employers. We all pay for our health insurance with our labor. In return for our labor, we receive a combination of cash, employer provided benefits and non-cash prerequisites. The amount that employers pay towards our health insurance premiums is part of our income, which is why we are taxed on our employer-provided insurance above a certain level. The government encourages employers to offer health insurance benefits by allowing the employer to deduct these expenses as a business expense. About 60% of us receive health insurance through our employer.

The elderly and the disabled are not physically capable of working. Employer-based health insurance does not work for them. They receive their health insurance through Medicare. Participants pay certain deductibles and co-payments, but the bulk of the cost is imposed on the rest of us in the form of a payroll tax and the government then pays medical providers.

So our health insurance system has become tied to employment. As the costs of health care rise, it is increasingly difficult for middle and lower income Americans to afford health insurance unless they get it through an employer. This is because, as I mentioned, an employer will partially subsidize the cost of the premium as a component of total compensation. In addition, an employer can offer access to a plan that includes many other workers, thus broadening the risk pool and lowering the overall premium for each worker. An individual who seeks to purchase health insurance on their own gets neither of these two advantages. As health care costs continue to rise (an annual increase of about 8% in recent years), this cost differential becomes more significant. Read more »

The Tweets:

Monday/The Anti-Injunction Act – Pay taxes now, sue later, delays the decision. Decide about penalties now.

Tuesday/Individual Mandate for Minimum Coverage – The mandate is too much or too little for the Commerce Clause.

Wednesday – Severability and Medicaid Expansion – Strike down the ACA if the mandate is unconstitutional because it’s all part of one plan or save as much as possible. Strike down the Medicaid expansion because the states foresee it will cost and confuse them as have past expansions. Read more »