The first hours of oral arguments in the Supreme Court on the constitutionality of President Barack Obama's signature health care reform legislation began on Monday.
The Affordable Care Act, which became two years old on Friday, has been targeted by generally Republican opponents for, among other things, being a government overreach, since it requires American citizens to have health insurance or pay a fine.
Brietta Clark, a professor of law at Loyola Law School in downtown Los Angeles who specializes in health care law and access issues, said the case against the constitutionality of the Affordable Care Act focuses on two aspects.
"Most people are aware of the challenge to the individual mandate," she said, "which would require that as of 2014 everyone either buy insurance or pay a fine if they don't qualify for some exemption."
The other has to do with the expansion of Medicaid. "Traditionally, Medicaid has only required coverage for certain groups, like pregnant women, children and people with disabilities." Clark said the expansion would require states to require all individuals, not just those "special classes," to be covered, as long as they meet income eligibility requirements.
For the individual mandate, Clark said that opponents criticize it as an inappropriate exercise of federal governmental power. She explained that there are exemptions to the mandate, however, and that it doesn't require every American to buy insurance.
"It says everyone should buy if certain criteria are met," she said. "But there are limits. If you fall below a certain income level, you are exempt from having to buy insurance, and with the Medicaid expansion, you may be eligible for the public insurance."
The Kaiser Family Foundation estimates that with these exceptions Clark referred to, millions of people could be exempt from the requirement to maintain coverage. Among those millions are people like members of certain religious groups and Native American tribes; undocumented immigrants (who are not legally eligible for health insurance subsidies); people whose income is so low they don't have to pay taxes ($9,500 for individuals and $19,000 for married couples); and people for whom health insurance is unaffordable (where insurance premiums, after employer contributions and federal subsidies, are more than 8 percent of family income).
And while people like the ones Kaiser mentioned will often be eligible for the expanded Medicaid coverage, people still will fall through the cracks, Clark said – despite U.S. Secretary of Labor Hilda Solis' claim to OnCentral on Friday that the ultimate goal of health care reform is to keep people from doing so.
"The poorest of the poor will be covered under the Medicaid expansion, as long as that's found constitutional, and people with good incomes will be fine," Clark said. "People who will be potentially left out are the working, lower middle-class who make too much to qualify for Medicaid but are trapped in an insurance market where it just costs too much."
Clark explained that health care reform creates "exchanges" – a market for purchasing health insurance where insurers come together so people can "go around and shop." It's a more affordable option that would give shoppers a reduced rate – but people who buy insurance through these exchanges will still be paying more than someone with employment-based health insurance.
"People who don't get to [buy health insurance] through their employer are still bearing full cost," said Clark, despite the reduced cost made possible by reform legislation. "Federal subsidies can help them pay, but that's still not going to approximate the savings we get from our employers."
As far as Medicaid, Clark said it was a federal versus state issue, and that opponents are calling the federal government's requirement that Medicaid be expanded "coercive" to the states. The professor said that argument was "shocking."
"The Supreme Court has long held that the federal government can create conditions for receiving federal funding," she said, adding that since the government is giving states money for this program, they have a right to tell states who must be eligible. Since the government is "creating the kind of conditions they've created for decades," Clark continued, she said she would be "utterly shocked" if this provision of the reform package was found to be unconstitutional.
In Part 2: A local health worker's take on the effect the Supreme Court Case could have on South L.A.; Clark's opinions on the constitutionality of the Affordable Care Act
Photo by Adam Fagen via Flickr Creative Commons.