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How Does The Ruling Change The Health Care Law?


The Supreme Court this morning upheld President Obama's health care law, finding its requirement that virtually all Americans buy health insurance constitutional. Five justices agreed that the requirement to have health coverage should be considered a tax and that Congress has the power, by the Constitution, to impose taxes.


And on the issue of the Medicaid expansion, a majority of the court said Congress can expand Medicaid but it can't penalize states of all their Medicare funds if they fail to carry out that expansion.

We're joined now by NPR health policy correspondent Julie Rovner and by NPR's White House correspondent Ari Shapiro.

Julie, first of all, we were concerned that it would take us all morning to explain the way that the health care law would be changed by this decision. And, in fact, not much changes.

JULIE ROVNER, BYLINE: Not much changes. That's right. The entire health care sphere has been, you know, bracing for what might happen and all the, you know, the chaos that might ensue from what the court might do. And the answer is really not much. This Medicaid change is a little bit - people are still trying to parse that out. But in terms of how the law goes forward from here, the law goes forward from here.

WERTHEIMER: Now, Julie, the court did narrow the Medicaid provision of the law by saying that states have the choice to opt into the Medicare expansion or not. And they don't lose anything except the additional money. But how is that - how will that work politically? What do you think states will be likely to do?

ROVNER: Well, you know, its Medicaid expansion. And, you know, the way - Medicaid has always been a voluntary program. And basically what the states argued is that Medicaid is now gotten so large that it's no longer voluntary; that every time the federal government says you need to do something to put more people on the Medicaid rolls, state have a choice of either doing it or losing all of their Medicaid money and they can't afford to say no.

So, basically what really, Chief Justice Roberts got the four liberal justices to go along with him, saying is that this expansion is so large - it's going to be another 17 million people, granted on a program that has about 50 million people on it - but this is so large that you can't say to the states, if you don't do the expansion we're going to take away all the rest of your Medicaid money. So it's basically made the expansion voluntary.

On the other hand, you know, this expansion comes with so much federal money. The federal government is paying 100 percent of it for the first few years. When it's completely in place, they're still going to be paying 90 percent of it. So I would think that the vast majority of states are going to take it. Some states have actually already started - they've started early. It doesn't begin until 2014.

But it was a, you know, a big federalism issue. And there may be some issues about this could have ramifications down the road for things other than Medicaid; does this limit the federal government's power to say what happens with federal dollars. I'm going to leave that to people more expert than I to determine if this will have ramifications beyond just this.


MONTAGNE: Yeah, what's interesting about this ruling, as well, is how much it is already beginning to sort of move back into the political realm. Very early in the chief's opinion, he wrote: We do not consider whether the act embodies sound policies. That judgment is entrusted to the nation's elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions.

So, let me turn to you, Ari. What has been the political reaction so far?

ARI SHAPIRO, BYLINE: Pretty much as you would expect, along party lines. Within the next hour, we're expecting to hear from both Mitt Romney, and then a little later, Barack Obama about the ruling. But we've already got reactions from Capitol Hill. House Speaker John Boehner put out a statement right away saying, today's ruling underscores the urgency of repealing this harmful law in its entirety. They've scheduled a House vote to repeal for the week of July 9th. They already voted once to repeal it, the Senate did not go anywhere with that.

Also, Nancy Pelosi, the Democrat who was speaker of the House when this bill passed - this is from an aid of hers. We're told that Pelosi called Vicki Kennedy, the wife of the late Senator Ted Kennedy who made health care his lifelong passion. Pelosi told Mrs. Kennedy, quote, "Now Teddy can rest." We're told that Nancy Pelosi is wearing her lucky purple pumps today that she wore on the day health care passed.


SHAPIRO: And then, on the Senate side, we had Mitch McConnell, the head of the Senate Republicans, saying this law was basically passed under false pretenses. They told us it was not a tax and today the Supreme Court said, surprise, guess what, it is a tax. And that's what makes it constitutional.

WERTHEIMER: So, do you think presumably the president will claim a victory and Mitt Romney will claim the need to get in there take this law down?

SHAPIRO: In a way, it's a winning day for both of them because, as you say, president Obama gets to claim a victory, that his law survived constitutional scrutiny from the Supreme Court. And I can tell you, having been at countless Mitt Romney rallies the biggest applause line at any of his rallies is: I will repeal Obamacare. Now he doesn't have to find a new applause line.

ROVNER: On the other hand, you know, here was Mitt Romney. What has the Supreme Court done? They have upheld the core of RomneyCare.

MONTAGNE: RomneyCare...


MONTAGNE: ...I was just going to ask that. I mean basically, in theory, he should be happy because this basically is saying what you put into effect in Massachusetts...

ROVNER: That's right. How many Republican debates did we listen to where we saw all of those other Republican candidates saying, Mitt Romney would be the worst possible candidate because, after all, he's going to go out and try and run against what is exactly what he put in place when he was governor.

SHAPIRO: Well, and politically there's been an interesting shift here, because Mitt Romney always portrays this health care law as an imposition by the government requiring people to have health care. And effectively, what the Supreme Court said today was no, no, no, no, this is not a requirement. This is a choice. You can either have health care or you can pay the tax. And it's up to you which one you want to do. This is a distinction without a difference.

In terms of policy, the policy hasn't changed at all. But in terms of the frame, Mitt Romney's constant discussion of the freedom of choice and the freedom of individuals to decide their own fate is something of that Supreme Court endorsed today, without striking down the Obama law by saying, yeah, this is a choice. It's not a mandate at all.

WERTHEIMER: Now, the two largest elements of the bill - the bill itself and then the Medicaid provision - both added millions of people to theoretically the list of people who are covered by insurance.

ROVNER: That's right. About 30 million people will be added. About half of them - little more than half of them through the Medicaid expansion, and the rest through this, through the mandate.


ROVNER: (unintelligible) through the mandate. And I should say, through the subsidies. There's an enormous amount of subsidies to help. It's not just a requirement that if you don't have insurance you buy it. If you can't afford it, there will be a lot of federal funds to help you purchase it.

WERTHEIMER: So that is perhaps the biggest change that we would be looking at down the road, is that President Obama will have done one of the things he said he wanted to do - cover more people, get more people on health insurance.

ROVNER: That's right. And that's why, you know, one of the huge ironies is that President Obama opposed the mandate when he was a candidate. Romney supported it, President Obama opposed it 'cause he was worried about this being not popular. But they explained to him that without this requirement you wouldn't be able to cover that many people.

MONTAGNE: And we are going to be covering this story for the rest of this show, MORNING EDITION. But, Julie Rovner, thanks very much.

ROVNER: You're very welcome.

MONTAGNE: Ari Shapiro, thank you very much. He'll be with us for this next half hour. I hope that you stay with us too.

SHAPIRO: Looking forward to it.

MONTAGNE: And we have been listening to coverage and will have continuing coverage about the Supreme Court decision to uphold the Affordable Care Act, known as president Obama's health care reform.

This is NPR News. Transcript provided by NPR, Copyright NPR.

As NPR's senior national correspondent, Linda Wertheimer travels the country and the globe for NPR News, bringing her unique insights and wealth of experience to bear on the day's top news stories.
Renee Montagne, one of the best-known names in public radio, is a special correspondent and host for NPR News.
Ari Shapiro has been one of the hosts of All Things Considered, NPR's award-winning afternoon newsmagazine, since 2015. During his first two years on the program, listenership to All Things Considered grew at an unprecedented rate, with more people tuning in during a typical quarter-hour than any other program on the radio.