On the day President Obama signed the legislation into law, several lawsuits were filed in federal courts nationwide challenging its constitutionality. These lawsuits raised many different arguments, but the central claims underlying all of the cases are enumerated below under Major Legal Arguments.

Virginia was one of the first states to challenge the health care legislation. Filed by Virginia Attorney General Kenneth Cuccinelli in the US District Court for the Eastern District of Virginia, Virginia v. Sebelius [PDF] resulted in Judge Henry Hudson ruing that the individual mandate was unconstitutional. The decision in Sebelius created a split at the district court level, as the US District Court for the Western District of Virginia had dismissed a similar challenge just two weeks earlier. The US Department of Justice (DOJ) appealed Judge Hudson’s ruling to the US Court of Appeals for the Fourth Circuit, which heard oral arguments in the case in May 2011. The Fourth Circuit rejected Virginia’s lawsuit in September 2011, ruling that the state lacked standing to sue. Numerous [https://www.justice.gov/healthcare] other challenges to the ACA were similarly dismissed for lack of standing, lack of jurisdiction, and other grounds by federal district courts.

The Fourth Circuit also presided over Liberty University v. Geithner, which originated from the US District Court for the Western District of Virginia and was similarly dismissed for lack of standing in September 2011. The court ruled that it could not address the issues raised in the lawsuit because it dealt with tax law issues that would not be ripe until the individual mandate took effect in 2014. Liberty University petitioned the US Supreme Court for certiorari in for certiorari was denied.

Numerous other challenges to the ACA were also dismissed for lack of standing by federal district courts in Missouri, the District of Columbia, New Jersey, New Hampshire, and Mississippi; this, too, was denied.

In June 2011, the US Court of Appeals for the Sixth Circuit upheld the individual mandate in Thomas More Law Center v. Obama. That lawsuit was originally brought by the Thomas More Law Center (TMLC) and was dismissed by the US District Court for the Eastern District of Michigan. The parties had held oral arguments before the court earlier that month. The Sixth Circuit’s ruling was described as “devastatingly convincing” by former US Solicitor General and JURIST Guest Columnist Charles Fried in Forum. TMLC became the first party to an ACA lawsuit to file a petition for certiorari in the US Supreme Court in July 2011.

In August 2011, the Eleventh Circuit held that the individual mandate is unconstitutional in Florida v. HHS [PDF]. Originally spearheaded by Florida Attorney General Bill McCollum, the coalition grew from 13 to 26 states and eventually included South Carolina, Nebraska, Texas, Michigan, Utah, Pennsylvania, Alabama, South Dakota, Louisiana, Idaho, Washington, Colorado, Georgia, Indiana, North Dakota, Mississippi, Nevada and Arizona. The lawsuit was also joined by a coalition of 13 state attorneys general and the National Federation of Independent Businesses (NFIB), who originally filed suit in the US District Court for the Northern District of Florida. District Judge Roger Vinson ruled the ACA unconstitutional in January 2011, striking down the law in its entirety. The Eleventh Circuit ruling narrowed this, however, finding the individual mandate unconstitutional and severable from the rest of the legislation.

Following the Eleventh Circuit’s ruling, both sides of the lawsuit petitioned the US Supreme Court for certiorari in late September 2011. Those petitions immediately followed the Obama administration’s decision to not seek en banc review from the Eleventh Circuit, which effectively cleared the path for an expedited appeal. The Supreme Court granted certiorari on November 14, 2011, agreeing to review the Eleventh Circuit’s ruling in Florida v. HHS [PDF], National Federation of Independent Business v. Sebelius [PDF], and HHS v. Florida [PDF] on a consolidated basis. It was the first ACA challenge to be granted certiorari. The federal government then filed a brief [PDF] in defense of the mandate as part of the larger health care regulatory scheme of ACA. Twenty-six states filed a brief [PDF] supporting the government’s argument.

The Court set aside five-and-a-half hours on March 26-28, 2012 for oral arguments in the case. In anticipation of the legal arguments, the government filed a brief [PDF] requesting an additional half hour of time for its argument in February 2012. Over the three days of oral argument in front of the Court, US Solicitor General Donald Verrilli agreed with challengers of the ACA that the Anti-Injunction Act of 1867, prohibiting lawsuits challenging a tax until that tax is collected, does not prohibit the Court from hearing the challenge.

Verrilli also argued that the ACA falls within Congress’s Commerce Clause power, despite Chief Justice Roberts’s observation that use of the power to require people to purchase services would be an unprecedented use. Washington attorney Paul Clement argued for the 26 states that the Court must strike down the entire ACA if it finds the individual mandate provision unconstitutional because the provision is integral to the law’s regulatory scheme, and that the expansion of the Medicaid program under the ACA amounts to unconstitutional coercion of states (exceeding Congress’s Spending Power) to participate in the regulatory scheme.

JURIST Guest Columnist Nicole Huberfeld expressed concern in Forum regarding the Court’s understanding of Medicaid:

Medicaid remains the black sheep of the health care reform litigation. Before the six-and-a-half hours of oral argument at the end of March, commentators focused primarily on whether Congress may require a minimum level of health insurance coverage. Even the number of amicus briefs filed (about 23 on the Medicaid issue versus about 78 on the “individual mandate”) indicates lack of attention to the spending question in Florida v. US Department of Health and Human Services. Both Solicitor General Donald Verrilli and Paul Clement referred to Medicaid as Medicare, a blunder that may be natural after three days of arguments. But, such stumbles suggested a lack of understanding of both spending doctrine and the Medicaid expansion and do not bode well for the Court’s decision-making processes.

A coalition of news organizations requested that the US Supreme Court allow live audio and video recording of the announcement of the decision. Two members of the US Senate Judiciary Committee, Patrick Leahy and Charles Grassley, also sent a letter to Chief Justice Roberts asking that the Court consider televising a live broadcast of its decision. The Supreme Court has never allowed immediate release of a recording of an announced opinion, and also refused to do so in this case.

A group of 90 women filed suit against Washington Attorney General Rob McKenna in state court for his participation in the Supreme Court challenge. The complaint alleged that his opposition to the ACA prevented women from accessing full medical coverage and sought a court order requiring McKenna to amend his pleadings to request that the Court uphold the women’s health provisions of the ACA. King County Superior Court Judge Sharon Armstrong denied the plaintiffs’ request for a preliminary injunction against McKenna.

On June 28, 2012, the US Supreme Court ruled that the ACA is constitutional, upholding almost the entirety of the law In the majority opinion [PDF] by Chief Justice Roberts, the Court held that the individual mandate was an invalid use of Congress’s Commerce Clause powers. The Court upheld the individual mandate, however, based on the federal government’s argument that the penalty levied against those who do not comply with the individual mandate can appropriately be classified as a tax. The decision also limited the new law’s Medicaid requirements, preventing the federal government from withholding existing funds from states that choose not to opt in to the ACA’s expanded coverage.

The decision also struck down the ACA’s Medicaid expansion as an overly coercive exercise of Congress’ Spending Power; the Roberts plurality found that the changes to the Medicaid program were not just a question of degree, but also kind. The Medicaid expansion sought to extend coverage to all non-elderly individuals earning up to 133% of the federal poverty line, constituting a shift in scope rather than an expansion of existing coverage for discrete categories of individuals. The rejection of the Medicaid expansion, which the Court likened to a “gun to the head” and an “economic dragooning” of the legislative and administrative apparatuses, surprised many experts. The Court’s holding ultimately prevented the federal government from withholding existing funds from states that choose not to opt in to the expanded coverage.
In February 2014, The Eastern Virginia District Court dismissed a challenge to the ACA in King v. Sebelius, which argued that the premium assistance subsidies the ACA awarded to individuals purchasing insurance in the marketplace was only available on state-run, rather than federally-run, exchanges. Following appeal, the Fourth Circuit affirmed the district court’s findings. On the same day, July 22, 2014, the D.C. Circuit held that tax credits were only available on state-run exchanges. The plaintiffs in King petitioned for certiorari, which the Supreme Court granted. In King v. Burwell, the Court looked at whether the ACA granted federally-run exchanges the same authority to issue subsidies to individuals as state-run exchanges. The Court grappled with the same textual questions that the lower courts debated: to wit, whether the words “such exchange” in the text of the law was meant to encompass both federal and state exchanges. The petitioners’ challenge to the IRS disbursement of subsidies had the potential to seriously cripple the ACA in the 34 states that opted to implement a federally-run exchange by hiking premiums, thereby making health care coverage unaffordable. Ultimately relying on the broader statutory scheme of the ACA and congressional intent, the Court held that making subsidies unavailable would send the health care marketplaces into a “death spiral” and, therefore, it was “implausible” to suggest that Congress would limit the availability of subsidies to state-run exchanges. The Court, thus, upheld the government’s position and the ACA survived its second Supreme Court challenge in three years.