ABSTRACT
For health law, ethics, and public policy, NFIB v. Sebelius is a once-ina-generation decision—perhaps even once in a lifetime. No case before it has had such monumental importance for how health care is financed and delivered in the United States, and it is hard to imagine when another case of this magnitude might arise. At stake was the entire Patient Protection and Affordable Care Act of 2010 (ACA, or Affordable Care Act, for short). The core of this massive law can be boiled down to the following central elements, each designed to make almost every American eligible for affordable coverage:
Medicaid expansion. The federal-state program for the poor expands to cover all citizens below 138 percent of the federal poverty level rather than restricting eligibility to categories of need such as disabled, elderly, or single parents.
No medical underwriting. Private health insurers may not refuse applicants or limit coverage based on actual or predicted health conditions. Also, insurers may not vary their rates based on prior or predicted use of services, other than a partial (but not full) adjustment for age.
Employer “play or pay .” Larger employers (more than 50 workers) pay a tax if they do not offer health insurance.
Subsidized insurance. Middle- and lower-income people who do not qualify for Medicaid or for employer-sponsored insurance will receive substantial government subsidies to buy private insurance through new “exchanges.”
Individual mandate. Everyone who has an affordable health insurance option (one costing less than 8 percent of household income) must sign up for at least minimum coverage or pay a modest tax penalty.
