Supreme Court to hear arguments on Obamacare: An enigma, based on a canard, wrapped in a conundrum.

Enigma, based on a canard, wrapped in a conundrum!

March 26, 27, and 28 2012, become the next significant dates in the future of the Affordable Care Act (ACA or Obamacare).  It is on these dates a little over two weeks from now that the Supreme Court will hear arguments both challenging the constitutionality of part of the legislation and arguments as to why the court should uphold the legislation. For most of us on both sides of the aisle, involved in the debate over healthcare reform, we see this as an enigma, for widely opposite reasons, as to how we have arrived today at this point.

For those of you that are interested in this current debate, you can find a number of places to read the arguments, or you can simply read someone else’s interpretation of the arguments.  Here, are some links:

My advice to you is, don’t rely on others interpretations, read the source documents for yourself.  Everyone, including me, are bringing their own bias to their review; some unintentionally, many intentionally.  This has become the partisan issue of this decade.  None of these arguments is a simple read for the non-lawyer.  I would argue that it is the view of a non-lawyer, the view of a common citizen that is now most required to be heard.  The lawyers now are so wrapped up in the history of all judicial actions, and their arguments are both driven by, and necessarily constrained by, the rulings that have preceded; the legal principle of stare decisis—Latin for stand by the decision—the obligation for the court to uphold what has gone before.  It is now, that someone, not a lawyer, needs truly to ask what is the right principle.

As James Madison wrote, “The powers delegated by the proposed Constitution to the federal government are few and defined. Those which are to remain in the State governments are numerous and indefinite.” This
constitutionally mandated division of authority was “adopted by the Framers to ensure protection of our fundamental liberties.”

I am not a lawyer, and I have my own biases.  I write this, not to tell you what to think, but to tell you how I have chosen to understand this issue.  I hope you will use this as a stimulus to plot your own quest for an answer.  We are at a point in our history that if we do not reengage as citizens, in an active role, in the formation of our governance, we will find that the government that we end up with, will be consumed by forces we do not want, nor can we afford.   The power of our “constitutional republican” form of government is based that the power comes from the people, is enacted by our representative people (the extension of us, not a special or elite class), and is for the benefit of us, the people. We are now at a critical juncture, where we, as a people, need to review the decisions we have allowed to be made and expanded like weeds in an uncultivated field, over the past seventy years.  We need to determine if what we now have accurately reflects what we intended; and if not, we need to no-longer allow the subtle expansion, and extension of federal powers, to continue indeterminately.

I am not arguing if we do, or we do not, agree with the constitutionality of the mandate in the Affordable Care Act.  That argument should come, but it needs to come after we determine if the precedent decisions, beginning with the pivotal case of Wickard v. Filburn reflect what we intended: and if it does not, then the pending arguments will continue to leave us sliding down the slope.  If it does, then we all must now accept the ramifications and understand the fundamental change to our current constitutional republican form of government that will fall out of these next actions.

For a review of the historical actions that have led to the current belief that the Federal Government can enact such a law, feel free to read my prior articles: Health Care Mandate and the Commerce Clause Articles, Entitlement vs. Safety Net: It’s not a matter of degree!, U.S. District Court of Appeals “Reaches” for the answer to the purchase mandate, and ACA, Politics, Mandates and the Commerce Clause.

The Arguments

As the Patient Protection and Affordable Care Act was passed, the controversy and the challenge began immediately.  Within hours of passage, states’ legislatures and attorneys-general began filing actions to block its implementation.  Some of these actions were new state laws that helped limit the laws effect.  But, the more effective challenges were the suits filed by the states to block the federal law’s implementation.

Numerous arguments were originally made to challenge the law.  Arguments that the act violated the constitutional right of privacy, violated the free exercise of religion, and even violated the thirteenth amendment prohibiting slavery, along with many others, were made.  As the cases have moved through the judicial system, the plethora of arguments has continually been pared down to a remaining few.  In a little over two weeks, the Supreme Court has agreed to hear a subset of the original arguments.

There are now two main questions pending from the original challenges and two additional questions posed by the court itself.

  • Remaining Questions
  1. Does the Individual Mandate clause exceed congress’s enumerated powers?
  2. Does the expansion of eligibility of Medicaid to include all legal citizens less than 65 years old and earning less than 135% of Federal Poverty Level (FPL)—approximately $37,500.00 per year—force the states to implement what is federal legislative power thereby violating the separation of powers principle?
  • Additional Questions
  1. Does the Tax Anti-Injunction Act bar the court from hearing the case?
  2. Is the mandated coverage constitutionality question severable from the remainder of the act?

Supreme Questions

In reading through the briefs and the summaries, available through the links above, I see the arguments breaking down this way. On the side to overturn the legislation, the arguments are framed as to whether, or not, the original intention of the commerce clause in the constitution, grants this right to the federal government, or does it remain as a right of the people i.e. the individual states.  The arguments for the act to be upheld seem to me based on legal tricks and gimmicks to justify the extension of the power based solely on the extensions that have gone before.  Perhaps this is not fair but I believe the fundamental question needs to supersede those decisions that have gone before, with which I think most Americans would also disagree.  I think it is mere trickery to cite one bad ruling as the basis for another if the root decision is in question.

Despite the tricks and histrionics on both sides, the basic argument comes down to, is it the federal government, or the state government, that have the authority to enact  legislation governing personal behavior.  The main argument for this federal right is the precedent cases, not the root argument of what the Commerce Clause actually means.  For me, it is this framing of the debate that is now the problem.  If the arguments are bound by the principle of stare decisis, then I believe the logical conclusion will be a 5 to 4 decision in favor of upholding the mandate in the ACA.  If the issues revert to the principal determination of whether, or not, the commerce clause was framed to grant any of the rights, now assumed by precedent, to the federal government, then I think we will have a 5 to 4 decision overturning at least the mandate portion of the law.  And, without the mandate, most believe that the ACA law becomes moot.

The secondary argument made by those in favor of the mandate follows the “everything now is interstate commerce” logic because if people do not conform to this mandated behavior then their actions become a fiscal drain on the rest of us, because either the industry, or the government now must go provide for their needs, and the cost will get passed back to the rest of us.  But, this argument is a canard.  The cost to us for lack of action by others is a real cost, but it is predicated by a government action of over forty years ago that mandates that we are going to provide the services in the second place when the individual fails to take appropriate steps to be responsible for their own needs in the first place.  By the way, I am not talking about eliminating a safety net.  We need a safety net!  Safety nets should be provided for the helpless.  What we have today is not a safety net, it is an entitlement, and while some helpless get benefit, predominantly it is providing support for the clueless and the worthless.

The recent Birth Control debate is a timely example.  Forget the religious argument; this is mere political theater at this point.  The argument goes like this.

Someone, employers or insurance companies, i.e. us due to cost shifting, must pay for birth control for women because it costs too much and they cannot afford it.  They will have sex and some will get pregnant.  They will then have babies because they cannot afford, or do not want, to get abortions. Then the government will have to pay to birth these children and support the mothers and their children causing a larger fiscal drain than the cost of birth control itself.

This is a canard because the requirement for the cost for the voluntary pleasurable act of sex, a biological drive, that may result in pregnancy and birth of a child, only places the cost of birth and support of the mother, and child, on us, because we have chosen to accept the responsibility of these costs in the first place.  I am not arguing whether or not we should do this.  I am simply saying we made a choice to do this, and to take the responsibility for the act off the participants and place it squarely in our collective laps.  To swallow the argument that one now begets the other is to believe that the requirement for us to absolve the participants of their personal responsibility and accept the burden of their actions is somehow inviolate and must remain so for all time.  This is simply false.

The humanistic, moral and ethical implications aside, we should be under no perpetual obligation not to revisit the original decision as to who is responsible for what in society.  There are many other cultures around the world that do not accept this responsibility at all, and often these acts result in poverty, pain and in some cases death to mothers and children.  We choose to be more humanistic, and believe ourselves more moral and ethical, and have chosen to believe that we are obligated to support those that will not support themselves.  Understand I am not arguing we should not do these things, I am just pointing out that this decision is both cause and effect on many others we now face.  It is political gamesmanship to present one side of a justification as fait a compli, this is routinely done in the body politic these days, and often fools us into limiting the debate and choices, yielding ineffectual results.

Another argument by the supporters of the ACA is based on the following quote,

“Opponents of the health care law say that if it is upheld, then government can force people to buy an American car or eat broccoli.  But, a person can opt not to drive a car or eat vegetables: no one realistically can opt out of health care.”

This argument follows, what is called in sales, “the Reverse Ben Franklin Close.”  In effect, this technique is geared to obscure the argument, by saying that you can be forced to buy a car and to eat broccoli if you are also forced to buy healthcare insurance, but unlike the others, you do need health care.  In effect, leaving the impression that they are not equivalent and therefore, the worry is not valid. The technique, not the argument, obscures the real issue.  Yes, you almost certainly will need healthcare as you live, and your need will grow proportionally to the length of time you live. But, the argument is that we have to pay for your healthcare not the fact that you need healthcare and don’t need broccoli or to drive.  We don’t pay for your car or vegetables.  That is ultimately the key question.  It is not the benefit of the ACA. The question is, at what point does a safety net come into play to serve the needs of the helpless.  How do we define the helpless?  And, how do we filter out the burden of the clueless and the worthless? Currently we have chosen to propound the philosophy that all people are now entitled to healthcare, regardless of their personal choices or life planning.  We do not as yet entitle people to a car of free vegetables.  The worry by some is that this is coming next.

Does the Individual Mandate exceed congress’s enumerated powers?

This question has become the key question and the key argument for, and against, the viability and continuance of this legislation.  Is the federal government authorized to require citizens to purchase health care and in effect penalize them in the form of a tax or a penalty if they do not buy insurance?  The crux of the argument, for this federal power, is a U.S. Supreme Court case that was argued in 1942, Wickard v. Filburn, 317 U.S. 111.  I have written about the case in my article, Health Care Mandate and the Commerce Clause. I will not rehash the case here but encourage you to go read the article and read the link to the case.

In reading this case, and the other cases that piggybacked on top of Wickard to justify the expansion of federal power, I have come to my own conclusions.  As you read those articles, you will find clearly what I believe.  The question is not what I believe, it is what you believe, and more importantly, what do we, the people, believe is the appropriate border line between where the state’s power begins and the federal power ends.

Does the expansion of eligibility of Medicaid to include all legal citizens less than 65 years old and earning less than 135% of Federal Poverty Level (FPL)—approximately $37,500.00 per year—force the states to implement what is federal legislative power thereby violating the separation of powers principle?

This issue in the end is a non-issue.  The crux of this argument hinges on one of the same tenants as the Mandate—where do the federal powers end and the state powers begin.  This argument began at the formation of the constitution in Philadelphia, and has continued to rage since the formation of the government, and the election of George Washington as the first president.  It was the main factor in the initial fractionalization of the founding coalition government in Washington’s first term, into one that had the federalists, headed by the strong central government vision of Alexander Hamilton, on one side, and the republicans, headed by the anti-monarchists, state’s rights principals of Madison and Jefferson, on the other side

Medicaid is a federal program.  In fact, Medicaid is an extension of Social Security, as is Medicare.  But, if you listen to the current administration they want it both ways.  On the one hand, the president calls Medicaid a state program, but, on the other hand, he wants the federal government to set the rules.  The state governors clearly and uniformly call Medicaid a federal program, and since it is breaking the banks of the states, would prefer to remove the expense from their books.  The conundrum is because in 1965, as President Johnson was framing the extension of the Social Security Act, the legislators know that they had to make Medicaid a “state” program or it would violate the separation of powers principles.

Does the Anti-Injunction Act bar the court from hearing the case?

This argument was raised in the case I discuss in U.S. District Court of Appeals “Reaches” for the answer to the purchase mandate.  In essence, there is an argument that the court should not be able to hear the case, because this act prohibits courts from preemptively enjoining any federal collection of tax revenue until after the revenue is collected.  The base argument is the court cannot enjoin the federal revenue stream until there is real harm.  I actually think the premise of this argument restricting courts below the Supreme Court is valid.  This act provides a check on the courts by eliminating a mechanism where lower courts could effectively shut down the federal government by strangling its cash flow.  I do not feel the same way at the level of the Supreme Court, in that, if it also binds the Supreme Court, the law would grant an unequal power to congress to prevent the Supreme Court from ruling on the constitutionality of some laws prior to harm being done. The Supreme Court is supposed to be the peoples effective check on the powers of congress to create bad law. I don’t think most of the justices are inclined to agree that Congress can pass a law that prohibits them from reviewing congressional actions.

Is the mandated coverage constitutionality question severable from the remainder of the act?

This is another interesting set of arguments and important to those arguing for and against the legislation.  When congress wrote this law they specifically excluded a clause that would allow for any section of the code that was found unlawful, or unconstitutional not to affect the other provisions.  So, on the face it would be argued that it was the intention of congress that all part of this law stands together, and if one part falls they all fall.  Of course, the counter argument is that since there is no statement that says that it all stands as one and it is not dividable on the merits then it must be severable.  I believe this argument is window dressing for the most part.  I believe the justices will rule with a significant majority that the law is severable.

In the end, the main piece is the Mandate. If the mandate falls, for the most part, the law falls.  If the mandate stands, than the law stands: another step in the additional extension of power to the federal government will occur and despite the contrite arguments from both sides, this new precedent will become the stage for another expansion later on.  If the mandate stands, Hamilton and his federalists would have been thrilled, and Madison,  Jefferson, and their republicans, would have been horrified.

The conundrum is that despite our best intentions, intelligence, humanity, economic analysis, and strong convictions, we have now created a major problem based on fundamental disagreement over what the founders intended and whether we are to stay true to this intention or if we should feel free to change it at will.  Frank Zappa once said, “The crux of the biscuit is the apostrophe!”  (There may be a few of you that actually know what this was in reference too, and for those that do, I apologize for the original context. If you know feel free to post in the comments area. I will post the explanation in a few days if others do not.)  I am using the statement to illustrate that the apostrophe of this conundrum is at the point that helping some people becomes detrimental to all people.  Spock said to Kirk, “Sometimes the needs of the many outweigh the needs of the few, or the one.”  This is a loaded statement, as the needs of the many may be affected in very dangerous and deleterious ways by catering to the needs of the many.  Sometimes, as in this case, society gets to the point where the definition of what is needed needs to be clear and it is imperative to prioritize the fundamental needs and eliminate the extraneous wants.

In the end, we are faced with an enigma, based on a canard, wrapped in a conundrum!  I hope we have the national and personal character to address the problems and find real resolutions.

 Note: I hope this article at least provides a process for you to seek your own answer.  I am sure once again we will be much divided, but perhaps the arguments can become fundamental and appropriate, and no longer tangential, and irrelevant. I ask you to come back and post your thoughts in the comment section.

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About Thomas W. Loker

Meet the Author - Thomas Loker is a Startup Consultant and Advisor at SYDK.ORG, Angel Investor, Mentor and Advisor at Keiretsu Forum & Venture-Med and an established operations guy with serial successes with startups, transitional companies and turnaround situations. He has had a long career serving in the fields of science, technology and healthcare related industries. He is an active board member in both for-profit and not-for-profit companies. Tom has written numerous articles in the areas of healthcare, technology, politics and the economy. He is currently the principal author of Health Reform 2.0: Beyond partisan divide lies pragmatic solutions – a whitepaper focused on moving beyond the partisan rhetoric of the ACA (Obamacare) to a simple, efficient, effective, accessible and affordable healthcare system. He maintains a passion for serving the underserved and has founded, supported and worked in various companies to serve the most fragile among us. Because of his expertise on the business of healthcare, he was invited to conduct multiple congressional briefings on healthcare reform in Congress, meeting with more than 100 congressional representatives. He has been a guest on HuffPost Live to talk about health care issues, and is a frequent keynote speaker on the topic for many groups and events. Prior to his latest book, The History and Evolution of Healthcare in America: The untold backstory of where we've been, where we are, and why healthcare needs more reform, Tom published “Delusional Ravings of a Lunatic Mind”—a collection of essays on healthcare, politics and their interaction with the economy, available at Amazon, Barnes and Nobles, and other bookstores. Tom's passion for Music is currently expressed by his role as VP Operations and General Manager of David Victor Presents. See www, to find out more. You can find Tom online at: Website: Blog: LinkedIn: Photography:

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