The Patient Protection and Affordable Care Act: Analyzing the Decisions

As of June 2011, five District Courts and one Circuit Court have issued opinions on the constitutionality of the Patient Protection and Affordable Care Act.   On October 7, 2010, Judge George Caram Steeh of the Eastern District of Michigan (Southern Division) issued his opinion in Thomas More Law Center v. Obama, case no. 10-CV-11156.  The Sixth Circuit affirmed Judge Steeh on June 29, 2011.  On November 30, 2010, Judge Norman Moon of the Western District of Virginia (Lynchburg Division) issued his opinion in Liberty University v. Geithner, case no. 6:10-cv-00015.  On December 13, 2010, Judge Henry E. Hudson issued his opinion in Commonwealth of Virginia v. Sibelius, case no. 3:10-cv-188.  On January 31, 2011,  Judge Roger Vinson issued his opinion in State of Florida v. United States Department of Health and Human Services, Northern District of Florida (Pensacola Division) case no. 3:10-cv-91 RV/EMT.  On February 22, 2011 Judge Gladys Kessler issued her opinion in Margaret Peggy Lee Mead, et al., v. Eric H. Holder, Jr. et al., USDC District of Columbia, civil action No. 10-950 (GK).  Each case has essentially focused on two issues: whether the Act’s Section 1501, the Requirement to Maintain Minimum Essential Coverage,  violates the Commerce Clause of the United States Constitution: and whether the penalty assessed against taxpayers who do not maintain the minimum level of coverage is a “tax” and therefore authorized under Congress’ taxing power.  These opinions are interesting but largely miss the mark in their analysis of whether the PPACA violates the Constitution.

Section 1501 starts by stating Congressional findings that insurance is interstate commerce, subject to federal regulation under United States v. Southeastern Underwriters Association, 322 U.S. 533 (1944); health insurance and health care services are a significant part of the national economy; the Act will add millions of consumers to the health care market;  and increasing the size of the pool, combined with required participation by healthy individuals, will significantly reduce administrative costs (which account  for 26 – 30% of premiums in the current market).  What the Act does not say, but what we also know to be true, is that Congress elected not to address this problem by instituting a “single payer” system to be run by the federal government.  However, the PPACA is still expected to be an expensive exercise for the federal government: the most recent estimates are +/- $1 trillion.  In addition, other provisions of the Act prohibit private insurers from denying coverage to  applicants based on pre-existing conditions, establishing lifetime coverage limits, and/or rescinding coverage (except in cases of fraud).  These new regulations would, in the absence of mandated minimum coverage, significantly drive up the cost to private insurers.    

The Act next requires that, starting in January 2014, all “applicable individuals” and their eligible dependents maintain at least the minimum essential coverage.  The term “applicable individuals” excludes members of religious groups who oppose health care; members of health care sharing ministries; illegal immigrants; prisoners; low income individuals for whom the minimum required payments would exceed 8 percent of household income; taxpayers with income under 100% of the poverty line; and members of Indian tribes.

The Act defines “minimum essential coverage” to mean any of the following: government sponsored programs (such as Medicare, Medicaid, and/or veteran’s health care programs); employer-sponsored plans; individual plans; grandfathered health plans; or state benefits risk pools.  The Act does not describe any minimum premium payments that  an individual must make in order to meet the “minimum essential coverage” standard. 

Individuals who do not maintain the minimum essential coverage (either for themselves and/or for applicable dependents) will be assessed a penalty, which is added to the individual’s federal tax bill.   The maximum amount of the penalty will be $95 per person ($285 per family) in 2014, $350 ($1,050) in 2015, and $750 ($2,250) in 2016 and thereafter (subject to cost of living increases).      

In each of the cases, the various governmental entity defendants have argued that the penalty is a “tax.”  This is because the Anti-Injunction Act, 26 U.S.C. § 7421, provides that “no suit for the purpose of restraining the assessment or collection of any tax shall be maintained in any court by any person, whether or not the person is the person against whom such tax was assessed.”  However, all four courts have held that the penalty is not a “tax” because it is intended to coerce compliance with the mandatory coverage provision, not to raise revenue.   

With respect to Congress’ ability to enact the mandatory coverage provision under the Commerce Clause, the courts are divided:

(a)   Thomas More Law Center v. Obama:  The plaintiffs argued that refraining from purchasing health insurance constitutes “inactivity”, and that Congress has never attempted to regulate “inactivity.”  They argued by analogy to United States v. Lopez, 514 U.S. 549 (1995), and United States v. Morrison, 529 U.S. 598 (2000).  In Lopez, the Supreme Court held that Congress could not criminalize possession of a firearm in a school zone, because possessing a gun in a school zone did not constitute economic activity.  In Morrison, the Court invalidated the Violence Against Women Act because of the lack of connection to interstate commerce.  Plaintiffs argued that the mandated coverage provision similarly lacked any nexus with interstate commerce because refusing to purchase health insurance is not an economic activity.   The Government argued that the controlling cases were Wickard v. Filburn, 317 U.S. 111 (1942), and Gonzales v. Raich, 545 U.S. 1 (2005).  In Wickard, the Court held that a farmer’s decision to grow wheat on his farm for his personal consumption affected interstate commerce because in the aggregate such decisions affected the price of wheat on the open market.   [The case involved a statute that imposed a penalty on exceeding wheat growing quotas: the Court rejected the argument that the penalty “forced” farmers to purchase wheat on the open market.]  In Raich, the Court upheld Congress’s authority to prohibit the growing of marijuana for personal consumption, based on the finding that the statute bore a rational relationship to Congress’ regulation of the “established and lucrative” (albeit illegal) marijuana market.   Based on these cases, the Government argued that Congress had the right to mandate the purchase of insurance as part of its overall regulation of the insurance market.

The Court held that the decision not to purchase health insurance until an individual becomes ill is an economic decision in that it shifts the burden of satisfying health care costs onto other participants, and that human beings cannot effectively opt out of the health insurance market.  The Court also held that the mandatory coverage provision was an essential component of the overall regulatory scheme, and was a reasonable means of effecting Congress’ goal of universal health coverage.

On June 29, 2011 the Sixth Circuit affirmed Judge Steeh in an opinion written by Justice Boyce F. Martin Jr., civil action no. 10-2388.  Justice Jeffrey S. Sutton concurred in the judgment, but wrote a separate concurrence; Judge James L. Graham, senior district court judge sitting by designation, dissented.  Justice Martin wrote that the minimum coverage provision was valid as a regulation of the activity of participating in the national market for health care delivery; deciding to self-insure (or risk retention) was one form of participation in the national market which had a substantial effect on interstate commerce.  Judge Martin also upheld the minimum coverage provision as an essential part of a broader economic regulatory scheme, i.e. the interstate markets in health care delivery and health insurance, which Congress has the power to regulate.  Justice Martin dismissed the “activity/inactivity” argument, noting that nothing in the Constitution prevents the regulation of “inactivity” and that the overwhelming majority of Americans will be “active” in the health care market because virtually everyone will require health services at some point in time.  The Sixth Circuit did not address the question of whether the provision was a valid exercise of Congress’ taxing power (although Judge Sutton stated in his concurrence that the provision was clearly not a “tax”).        
(b)  Liberty University v. Geithner: The plaintiffs challenged both the mandatory coverage provision and the provision requiring employers to offer health insurance coverage to their employees.   Once again, the plaintiffs argued that the decision to forego health insurance was not an economic activity, but instead was a decision not to engage in interstate commerce.   The Government noted that because hospitals are required under the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd, to provide emergency room treatment to patients without regard to their ability to pay, the decision not to purchase health insurance shifts the costs of such emergency services onto those who do purchase insurance in the form of higher premiums (resulting from increased healthcare costs).

The Court relied on the Wickard and Raich in holding that decisions about how and when to purchase health insurance were economic in nature, in that virtually everyone is a participant in the health care market , and “inactivity” is in fact a decision to defer purchase of health insurance until an individual becomes ill.  The Court analogized the asserted decision to pay for medical services out of pocket to the famer’s decision in Wickard to grow wheat for his own personal consumption.   The Court further held that it was rational to believe that striking down the mandated coverage provision would undercut the larger regulatory scheme and purpose of the Act.  Finally, the Court held that a rational basis existed for Congress to regulate the terms of health coverage offered by employers, because such plans have a substantial effect on interstate commerce in that health insurance is a vital concern to employees.

Current status: on appeal to 4th Circuit (Judges Diana Gibbon Motz, Andre M. Davis, James A. Wyan); oral arguments heard May 10, 2011.

(c)   Commonwealth of Virginia v. Sibelius: The plaintiffs and the Government put forth essentially the same arguments as in the Thomas More and Liberty University cases.  However, in Commonwealth the Court held that in order to survive a constitutional challenge, the subject matter of the statute must be “economic in nature” and “affect interstate commerce,” and it must also involve “activity.”  [Somewhat contradictorily, the Court also stated that Congress’ ability to regulate interstate commerce extends to noneconomic activity that is “closely connected” to the intended market, citing Hoffman v. Hunt, 126 F.3d 575 (4th Cir.1997).]  The Court held that no authority allows Congress to compel an individual to involuntarily enter the stream of commerce by purchasing a commodity in the private market (ignoring the fact that the Supreme Court dismissed a similar argument in Wickard).  The Court declined to find the entire Act unconstitutional; instead, the Court severed Section 1501 and directly-depended provisions referring to Section 1501 and applied its ruling only to that provision.

Current status:   on appeal to 4th Circuit (Judges Diana Gibbon Motz, Andre M. Davis, James A. Wyan); oral arguments heard May 10, 2011.

(d)  State of Florida v. Dept. of Health and Human Services: This case was brought by the Attorneys General of 26 states[1].  Ominously, Judge Vinson commenced the opinion by announcing that the case was not really about the health care system, but rather was about the federal system as a whole.  Accordingly, the Court quoted extensively from the Federalist Papers, which it declared “has always been considered of great authority” and “is a complete commentary on our Constitution.”   The two claims before the Court alleged that (1) the individual mandate set forth in Section 1501 violated the Commerce Clause, and (2) the expansion of Medicaid to include individuals under age 65 with incomes equal to or less than 133% of the poverty level, and the aspect of the Act requiring that states to provide Medicaid services, violated the Spending Clause[2].  The Court initially addressed the second issue, stating the plaintiffs’ claim as alleging that the Medicaid provisions were “coercive and commanding” in that they essentially required the states to spend money they do not have.   The Court rejected this argument, holding that (1) it was not supported by case law and (2) the Medicaid program is voluntary, and no state is required to participate in it.  In so holding, the Court noted that every federal court that has ruled on the argument has rejected it. 

With respect to the individual mandate, the Court initially rejected the Defendants’ challenges to the Plaintiffs’ standing.   The Court then analyzed the historical intent of the Commerce Clause, concluding that Congress intended it to eliminate barriers and restrictions between states with respect to trade.   Next, the Court noted that starting in 1937, with cases reviewing the constitutionality of statutes passed as part of the New Deal, the Supreme Court expanded the reach of the Commerce Clause to affect purely intrastate activities that had a “substantial effect” on interstate commerce.   The Court noted that from 1937 until the Lopez decision in 1995, the Supreme Court did not find any regulations violative of the Commerce Clause.  In evaluating the four seminal cases (Wickard, Raich, Gonzalez and Morrison), the Court cited U.S. v. Maxwell, 446 F.3d 1210 (11th Cir. 2006), for the notion that the distinguishing factor was “the comprehensiveness of the economic component of the regulation.”   According to Maxwell, the statute in Lopez was “a brief, single subject criminal statute that did not regulate any economic activity.”  In contrast, the statute in Raich was “a broader legislative scheme at the opposite end of the regulatory spectrum.”  However, after this broad and far reaching discussion of constitutional law, the Court shifted gears and based its decision on the simplistic notion that Congress may only regulate “activity” and the individual mandate seeks to address “inactivity” (“[i]t would be a radical departure from existing case law to hold that Congress can regulate inactivity under the Commerce Clause.”).  In response to the Defendants’ argument that no case has ever held that the Commerce Clause turns on “activity,” the Court simply stated that “the Supreme Court has never been called upon to consider the issue because, until now, Congress had never attempted to exercise its Commerce Clause power in such a way before.”  The Court held that “inactivity” does not have a substantial effect on interstate commerce, and therefore Congress may not reach it.  To hold otherwise, in the view of the Court, would give the Commerce Clause “unlimited application.”  With respect to Defendants’ argument that the Necessary and Proper Clause gave Congress the right to enforce the individual mandate, the Court held that this Clause provides a means allowing Congress to accomplish an end specified in an enumerated power, but does not allow Congress to do what it otherwise lacks the authority to do.  Once the Court found that the Commerce Clause did not give Congress the power to pass the individual mandate, it followed (according to the Court) that the Necessary and Proper Clause could not grant Congress this power.  Finally, the Court held that the individual mandate was not severable, noting both the lack of a severability clause and Defendants’ argument that the mandate was critical to the Act as a whole.  The Court called upon Congress to review the Act and determine which parts could survive without the individual mandate, and which parts could not.  In a footnote, the Court noted that in 2008, then-senator Obama advocated for a health care reform program that did not include an individual mandate.               

Current status: on appeal to 11th Circuit (Judges Joel F. Dubina, Frank M. Hull, Stanley Marcus); oral arguments heard June 8, 2011.

(e)   Margaret Peggy Lee Mead, et al., v. Eric H. Holder, Jr. et al., USDC District of Columbia, civil action No. 10-950 (GK), memorandum opinion dated February 22, 2011:  Plaintiffs in this matter challenged Section 1501 on two grounds: violation of the Commerce Clause, and violation of the Religious Freedom Restoration Action of 1993, 42 U.S.C. § 2000bb et seq.  In addition, Defendants asserted as an affirmative defense that Section 1501 was a valid exercise of Congress’ taxing power under the General Welfare Clause (aka the Taxing and Spending Clause), 26 U.S.C. § 5000A(b).  The presiding Judge, Gladys Kessler, was a Clinton appointee.  Preliminarily, Judge Kessler found that all but one of the Plaintiffs had standing to bring the action, and that the Court had subject matter jurisdiction.

With respect to the Commerce Clause, Judge Kessler found that the individual mandate did not exceed Congress’ authority to regulate interstate commerce.  Judge Kessler initially noted the presumption that Congressional actions are lawful.   Relying on the Lopez and Morrison decisions, the Court held that a regulation may be upheld if it is an essential part of a larger regulation of economic activity, in which the regulatory scheme could be undercut unless the intrastate activity were regulated.  Next, Judge Kessler held that an individual’s decision either to purchase or not to purchase health insurance is an “economic” decision, in that the decision to forego health insurance leads to substantially higher premiums for individuals who do purchase coverage.  Judge Kessler dismissed the assertion of economic “activity” versus “inactivity” as “pure semantics,” stating that “[m]aking a choice is an affirmative action, whether one decides to do something or not do something.”  The Court also noted that the health care market differs from other markets in that medical providers may not refuse to provide basic medical services, regardless of the individual’s ability to pay.  This fact, combined with the fact that virtually all people will inevitably require some form of medical treatment at some point in their lives, guarantees that “nearly all individuals, rich or poor, are or will be consumers of medical services.”  Accordingly, the Court concluded that the only real issue is how health care services are to be paid for and who pays for them; Congress has the power to regulate the class of individuals participating in the health care market.

Consistent with the other district Court opinions, Judge Kessler held that the penalty assigned under the shared responsibility payment provision, 26 U.S.C. § 5000A(b), is not a “tax” and therefore the General Welfare Clause does not operate as alternative authority for Section 1501.

Finally, Judge Kessler made short shrift of Plaintiffs’ argument that §1501 violated the Religious Freedom Restoration Act.  Plaintiffs’ argument as characterized by Judge Kessler was that Plaintiffs believe in trusting in God to protect them from illness or injury, and being forced to buy health insurance conflicts with this belief because it would be an indication a lack of faith.  The Court held this to be a de minimus burden, noting that Plaintiffs “routinely contribute to other forms of insurance, such as Medicare, Social Security, and unemployment taxes, which present the same conflict with their belief that God will provide for their medical and financial needs.”  The Court also held that individual mandate serves a compelling public interest, and that Section 1501 is the least restrictive means of furthering this compelling interest.       

Current status: on appeal to D.C. Circuit (Judges Brett Kavanaugh, Harry Edwards, Laurence Silberman); oral arguments scheduled for Sept. 23, 2011.

 In each case, the courts parsed the issues unnecessarily.  Commentators have suggested that the decisions are all politically motivated (the judges upholding the statute were Democratic appointees, while the judges striking the statute down were Republican appointees).  Whatever the reason, the opinions either ignore or  fail to appreciate the following points:

  1. It is undisputed that, under United States v. Southeastern Underwriters Association, 322 U.S. 533 (1944), the business of insurance is a form of “commerce” which Congress may therefore regulate under the Commerce Clause.  [The McCarran-Ferguson Act, 15 U.S.C. § 1012(b), provides that federal law will not pre-empt state laws regulating insurance unless the federal law “specifically relates to the business of insurance.”  Barnett Bank, N.A. v. Nelson, 517 U.S. 25, 38 (1996).]  The PPACA, clearly and unequivocally, relates to the business of insurance, because it is specifically designed to regulate the creation, marketing, and sale of health insurance.  This fact alone distinguishes the PPACA from the statutes at issue in Lopez and Morrison.  In Lopez, the subject of the statute was the possession of a firearm in a school zone.  If the statute had addressed the manufacture, marketing, or sale of firearms, it would most certainly have been within Congress’ regulatory powers as provided by the Commerce Clause.  Similarly, the PPACA cannot reasonably be characterized as being limited to addressing the possessionof health insurance; rather, it is a comprehensive statute created to address health insurance with respect to consumers, physicians, and carriers.         

    Comparison to Morrison underscores the same point.  The statute in Morrison had as its sole focus the issue of domestic violence.  Unlike Southeastern Underwriters, there was no prior case law interpreting the Commerce Clause to grant Congress the power to regulate domestic violence.  While domestic violence is a serious issue worthy of attention, it is not affected by the trade between states; while it has an indirect impact on commerce (by affecting the ability of individuals to engage in commerce), it does not constitute “commerce” in the same way that the purchase of health insurance does.  Therefore, these cases do not aid in the intellectual analysis of the PPACA.

  2. The “activity v inactivity” analysis is a false distinction which does not add to the analysis.   Article I, Section 8, Clause 3 states that Congress has the power “[t]o regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes . . .” There is no mention of “activity” or “inactivity” in the Constitution.   Moreover, there is nothing unusual about the notion of Congress requiring individuals or companies to conduct “activities” or to pass laws prohibiting forms of “inactivity.”  See, e.g., Interstate Commerce Commission v. Goodrich Transit Co., 224 U.S. 194 (1912) (requiring common carriers to adopt uniform standards of bookkeeping, accounting, and annual reports).  In a similar fashion, the current iteration of the Selective Service Act requires selective service registration by all males between the ages of 18-25 years old; willful failure to register is punishable by fine.   Finally, the PPACA does in fact address “activity,” i.e., the design, marketing, sale, and purchase of health insurance.  The Sixth Circuit’s opinion in Thomas More is the lone opinion to fully grasp this concept. 
  3. The Necessary and Proper Clause, Article I, Section 8, Clause 18, states that “The Congress shall have Power – To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof.”   As Justice Vinson correctly noted in State of Florida v. Sibelius, the Necessary and Proper Clause “vests Congress with the power and authority to exercise means which may not in and of themselves fall within an enumerated power, to accomplish ends that must be within an enumerated power.”   Judge Vinson went on to correctly note that the regulation of health insurance is clearly “legitimate” and “within the scope of the Constitution.”  However, Judge Vinson then undercut his own logic by declaring that the means must be “appropriate” and not “inconsistent with the letter and spirit of the Constitution.”  In other words, Judge Vinson held that, contrary to the express language of the Constitution, Congress does not have power to make all laws which shall be necessary and proper for regulating health insurance, but only those laws which are “appropriate” and “not inconsistent with the letter and spirit of the Constitution.”  In so holding, he essentially re-visits the 16th Century argument between Jefferson and Hamilton regarding the scope of the Clause, which Justice Marshall laid to rest in McCulloch v. Maryland,17 U.S. 316 (1819) when he stated:

    The subject is the execution of those great powers on which the welfare of a Nation essentially depends. It must have been the intention of those who gave these powers to insure, so far as human prudence could insure, their beneficial execution. This could not be done by confiding the choice of means to such narrow limits as not to leave it in the power of Congress to adopt any which might be appropriate, and which were conducive to the end. This provision is made in a Constitution intended to endure for ages to come, and consequently to be adapted to the various crises of human affairs. To have prescribed the means by which Government should, in all future time, execute its powers would have been to change entirely the character of the instrument and give it the properties of a legal code. It would have been an unwise attempt to provide by immutable rules for exigencies which, if foreseen at all, must have been seen dimly, and which can be best provided for as they occur. To have declared that the best means shall not be used, but those alone without which the power given would be nugatory, would have been to deprive the legislature of the capacity to avail itself of experience, to exercise its reason, and to accommodate its legislation to circumstances.        
    at p. 415 (emphasis added).

    As such, because the individual mandate is a necessary part of the overall regulatory scheme, the overall regulatory scheme is constitutionally valid; because nothing in the Constitution expressly forbids the imposition of the individual mandate, this provision is a proper exercise of Congressional power under the Necessary and Proper Clause.

  4. The final misconception in these cases is that the PPACA “requires” individuals to purchase health insurance.  To the contrary, individuals (leaving aside those who are excluded from the mandate by reason of income level) have the choice of either obtaining employment with an employer who provides health insurance; purchasing health insurance; or paying a penalty.  [Note that, as part of the PPACA, employers above a certain size are required to provide health insurance for their employees, either by the purchase of group coverage or by payment into an insurance exchange; the penalty for noncompliance is a similar fine.]  The failure to purchase health insurance is not considered “criminal” conduct, and does not result in the loss of life, liberty, or property.   Rather, as the court noted in Liberty University v. Geithner, the resulting penalty is properly considered a “fee” and is a legitimate means of regulating commerce.  Id.    

There are well founded concerns regarding the PPACA, not the least of which are the potential costs involved; the availability of health care providers to serve the anticipated influx of customers into the system; and the quality of care that will be available.  However, a close and correct reading of the Constitution reveals that the Founding Fathers do not stand in the way of Congress’s effort to make affordable health care a fundamental right for all American citizens. 

Opinions Holding that the Plaintiffs lack standing

In addition to the cases cited above, the following opinions have dismissed constitutional challenges to the PPACA on the grounds that the Plaintiffs did not have standing the challenge the Act:

  1. Steve Baldwin and Pacific Justice Institute v. Sebelius, U.S.D.C. Southern California, case no. 10CV1033 DMS (on appeal to 9th Circuit, oral argument scheduled for July 13, 2011)
  2. Shreve v. Obama, U.S. Dist. LEXIS 118631 (E.D. Tenn. Nov. 4, 2010)
  3. N.J. Physicians v. Obama, 2010 U.S. Dist. LEXIS 129445 (D.N.J. Dec. 8, 2010)
  4. Kurt Joseph Van Tassel v. United States of America, case no. 1:10CV310, U.S.D.C. Middle District of North Carolina, Dec. 16, 2010
  5. Bryant v. Holder, 2011 U.S. Dist. LEXIS 23975 (S.D. Miss. Feb. 3, 2011)
  6. Harold Peterson v. United States of America, 2011 U.S. Dist. LEXIS 34775 (D.N.H. March 30, 2011)
  7. Purpura v. Sebelius, 2011 U.S. Dist. LEXIS 43153 (D.N.J. April 21, 2011)
  8. Kinder v. Geithner, 2011 U.S. Dist. LEXIS 45067 (E.D. Mo. April 26, 2011)

Other Challenges to the PPACA

In addition to the cases addressing Section 1501 and standing, the following opinions have asserted other challenges to the PPACA:

  1. New Jersey Physicians, Inc., et al v. Obama, 2010 U.S. Dist. LEXIS 129445 (D.N.J. Dec. 10, 2010) – a physician and a physician’s association alleged that they had standing to challenge the Act on the grounds that it affected their ability to treat patients and seek payment for medical services.  The Court granted Defendants’ Motion to Dismiss, holding that the Act neither prohibits patients from paying a physician directly nor dictates the delivery of medical services.
  2. Physician Hospitals of America, et al., v. Sebelius, 2011 U.S. Dist. LEXIS 35491 (E.D. TX March 31, 2011) – Plaintiffs challenged an amendment to the Medicare Act limiting their ability to bill for services provided to Medicare patients.  The Court granted Defendants’ motion for summary judgment, holding that § 6001 of the PPACA did not violate the substantive due process and equal protection clauses.  (Plaintiffs have appealed to the 5th Circuit)


[1] AL, AK, AZ, CO, FL, GA, ID, IN, IA, KS, LA. ME, MI, MS, NE, NV, ND, OH, PA, SC, SD, TX, UT, WA, WI, WY.

[2] The plaintiffs also alleged that the Medicaid provisions of the Act violated the principles of federalism defined under the Ninth and Tenth Amendments, but (according to the Court) essentially abandoned that argument.  


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