The Patient Protection and Affordable Care Act in the courts

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The Patient Protection and Affordable Care Act was a piece of legislation designed to enact sweeping reform to the national healthcare system. It was passed by the 111th United States Congress and signed into law by President Obama on March 23, 2010.

History of the bill

The bill, also known as, H.R. 3590, was originally introduced in the House of Representatives as the Service Members Home Ownership Tax Act of 2009 on September 17, 2009. It passed the House on October 8, 2009 and then passed the Senate, with amendment, on December 24, 2009. It was finally signed into law by President Obama on March 23, 2010.[1]

Constitutional challenges

Since the signing of the bill into law it has faced many challenges as to its legality on various constitutional fronts. It has been the subject of federal lawsuits filed by many states, individuals, and organizations. The majority of the legal arguments in these lawsuits maintain that the bill violates Article I, the Fifth Amendment, and/or the Tenth Amendment of the constitution. Some lawsuits have also been filed arguing violation of the First, Third, Fourth, Ninth, Fourteenth Amendments, and Articles II and IV.[2][3]

States' lawsuits

See here for more information on each attorney's general response.

In total, 28 state have filed suit against the federal government over the act. Of this number, 26 have sued as part of a multi-state lawsuit, Florida v. United States Department of Health and Human Services, filed in the Northern District of Florida.[3] Virginia has filed its own independent lawsuit, Commonwealth of Virginia v. Sebelius,[3] as has Oklahoma.[4]

Multi-State Lawsuit

The federal lawsuit filed in Florida, sometimes called the Multi-State Lawsuit, consists of 26 states, two individuals, and an independent organization. A listing of the plaintiffs is as follows: The Attorneys General of Arizona, Indiana, Mississippi, Nevada, North Dakota, Alabama, Colorado, Florida, Idaho, Louisiana, Michigan, Nebraska, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Washington, Georgia, Alaska, Ohio, Wisconsin, Kansas, Maine, Iowa, and Wyoming, Mary Brown and Kaj Ahlburg, and the National Federation of Independent Business.[5]

The lawsuit was brought to the federal District Court for the District of Northern Florida by Florida state Attorney General Bill McCollum on March 23, 2010. Florida was joined at the time by South Carolina, Nebraska, Texas, Utah, Louisiana, Alabama, Michigan, Colorado, Pennsylvania, Washington, Idaho and South Dakota.[6] Following this original action other states began considering joining the suit, and on Friday, May 14, 2010, Arizona, Indiana, North Dakota, Mississippi, Nevada, Georgia and Alaska, along with the National Federation of Independent Businesses (NFIB), formally joined with the filing of an amended complaint.[7] At this time individuals, Mary Brown and Kaj Ahlburg, also joined the complaint.[8] On January 19, 2011, Ohio, Wisconsin, Iowa, Kansas, Wyoming and Maine were granted permission by the court to join the lawsuit.[9]

This lawsuit challenges the Affordable Care Act on the grounds that the individual health insurance mandate exceeds Congress's authority to regulate interstate commerce under the Commerce Clause of Article I. The lawsuit also sues that the individual mandate does not fall within Congress's powers to tax. The complaint further alleges that the act violates the Tenth Amendment by infringing on state sovereignty by compelling it to follow federal regulations.[10]

This lawsuit has received rulings from the Northern District of Florida, Eleventh Circuit Court, and the U.S. Supreme Court.

Complaints and amendments

Below is a list of the complaints filed in the District of Northern Florida and the subsequent amendments.

  • Original complaint, retrieved from Florida Attorney's General office website on the lawsuit, filed March 23, 2010
  • Amended complaint, retrieved from Florida Attorney's General office website on the lawsuit, filed May 14, 2010
  • Second amended complaint, retrieved from Florida Attorney's General office website on the lawsuit, filed January 1, 2011

Virginia lawsuit

On March 22, 2010, Virginia Attorney General Ken Cuccinelli announced that the state would be filing suit against the federal government as soon as the act was signed, and indeed, did so on March 23, in the District Court for the Eastern District of Virginia. Cuccinelli has stated that he believes the state of Virginia to be in a unique position to sue because in 2010 the state passed a statute, Virginia Code 38.2-3430.1:1, declaring no resident of the Commonwealth of Virginia shall be required to have insurance or be penalized for not having it.[11][12] The case was filed as Commonwealth of Virginia v. Sebelius.

In the complaint filed, the state argued that the individual mandate exceeded powers granted to Congress by the commerce clause of Article I. It further asked that they entire act be declared invalid because the individual mandate is an "essential, non-severable" provision. Cuccinelli also asked the court to declare Virginia Code 38.2-3430.1:1 a valid exercise of state power.[13]

So far the Eastern District of Virginia and the Fourth Circuit Court have ruled on this lawsuit.


Below is the complaint filed by the state of Virginia.

Oklahoma lawsuit

Original filing

On January 7, 2011, Oklahoma Attorney General Scott Pruitt announced that the state of Oklahoma would files its own lawsuit in the Eastern District of Oklahoma independently of the Virginia suit and the multi-state suit filed in Florida. Pruitt stated that because it has amended its constitution to prevent citizens from being forced to obtain health insurance, and because it is in a position to learn from filings in Virginia and Florida, the state has good reasons for filing independently. In a press release stating his intention to sue, Pruitt commented on his decision to file within the state saying, "The most logical way to defend our state Constitution is in an Oklahoma federal court not in another state."[14] The case was then filed as Oklahoma v. Sebelius on January 21, 2011.

The complaint filed in federal court resembles the Virginia filing closely in its chief arguments. Namely, it take issue with the individual mandate and asserts that Congress overstepped its authority as granted by the Commerce Clause of Article I. Like the Virginia complaint, the Oklahoma filing also states that the entire act should be voided because the mandate in an "essential, non-severable provision". The state also requests that a permanent injunction be made forbidding the government from enforcing the mandate in particular and the act as a whole.[15]

The was stayed by Judge Ronald White until the Supreme Court issued a ruling in the multi-state case.[16]

Amended filing

On September 19, 2012, Attorney General Pruitt filed an amended complaint with the U.S. District Court for the Eastern District of Oklahoma that challenges the federal government's implementation of certain parts of the act. Specifically, the new claims argue that the act only allows state-based healthcare exchanges to provide tax credits on premiums for low-income employed individuals and therefore the new IRS rule, which guarantees such tax credits for individuals in states with federal-based exchanges, conflicts with Congress's intentions. According to the filing, employers of those who receive tax credits after opting for a healthcare plan from a federally run exchange will be subject to costly obligations in the form the employer mandate. The complaint alleges that this IRS rule, called the "Final Rule," violates the Administrative Procedures Act and asks the court to declare it invalid.[17][16]

Complaint and amendment

Below is the complaint filed by the state of Oklahoma.

  • Copy of complaint, retrieved from Oklahoma Attorney's General website, filed on January 21, 2011
  • Amended complaint, retrieved from Oklahoma Attorney's General press release on the lawsuit, September 19, 2012
This map highlights the various states' responses

Comparing the states' legal actions

Legal actions taken by the states vary, with some choosing to act before the passing of the bill, some after the passing, and yet others did both. The actions include public referenda, lawsuits, and signing legislation into law that directly countered the federal bill, and most notably, the individual mandate. Refer to the map to the right for a comparison.

Other notable lawsuits

See here for a list of cases related to the Patient Protection and Affordable Care Act.

Liberty University lawsuit

On July 30, 2010, a lawsuit was filed by Liberty University and several individuals challenging the act under Virginia law, much like the Virginia state lawsuit. The original filing of the suit takes issue with the potential for public funds to be used for abortion and claims that the act shows preference for certain religion over others by being selective about those for which it offers exemptions. The suit also alleged that the act violates the constitutional guarantee of a Republican form of government.[18]

Though the original suit was dismissed by the United States Court of Appeals for the Fourth Circuit in 2011, the Supreme Court has ordered that the court reopen the case. The Supreme Court issued the order explaining that the suit remains active following its National Federation of Independent Business v. Sebelius, the multi-state lawsuit, ruling because Liberty University's challenges are to the employer mandates rather than the individual one. Since its original filing, the lawsuit has expanded to include a challenge to HHS contraception mandate.[19][20]

Ballot measure challenges

Beginning early on during congressional debate over the bill, several legislative referrals and citizen initiatives appeared seeking to stop implementation of the act in a number of states. Most of these ballot measures proposed an amendment to the state's constitution declaring that citizens of the respective state could not be compelled to purchase health insurance or be fined for not doing so. Some measures, however, instead chose to focus on prohibiting the state's government from establishing a health insurance exchange. This particular tactic was used so as to gain additional legal leverage before the courts by making available the argument that the federal law violated state constitutions. Another aspect of this strategy was to demonstrate public disapproval of the bill by having such constitutional changes be decided by voters rather than state legislators. This effort was not universally successful however, because some states' voters refused to approve these constitutional amendments. Interestingly, despite Florida being at the forefront of the massive lawsuit that finally reached the U.S. Supreme court, its own such amendment failed during the 2012 general election.

The following is a list of states that saw such constitutional amendments on their ballots since 2008. Successful measures are indicate with a ApprovedA.

Court action

This section details the various court rulings and action taken in lawsuits relevant to the Patient Protection and Affordable Care Act. The section is broken down into circuits and the districts under their jurisdiction.

Supreme Court of the United States

On November 14, 2011, the Supreme Court announced that it would hear the appeal of the multi-state lawsuit filed in Florida. At the time the court said it would take up two issues: the question of whether or not the individual mandate is constitutional, and if it is not, can it be severed while leaving the rest of the act intact. Five and a half hours of oral arguments were set aside and are likely to begin in February or March of next year with a ruling is possible by June.[21]

On Thursday, June 28, 2012, the case was decided when the Supreme Court ruled 5-4 in favor of upholding the act.

The court ruled first on the individual mandate. Though the court rejected the mandate in respect to arguments that Congress was using power given it by the Commerce Clause, it was ultimately upheld as an exercise in Congress's ability to impose a tax. Essentially the court ruled that the penalty for not carrying health insurance is a tax, and individuals are free to opt to pay it instead of complying with the mandate. Chief Justice John Roberts delivered the majority's opinion saying, "the mandate can be regarded as establishing a condition -- not owning health insurance -- that triggers a tax -- the required payment to IRS." As a result of the mandate surviving the challenges to its constitutionality, the court did not rule on the issues of whether or not that part of the act could be severed from the rest.[22][23]

The second item the court ruled on was the act's expansion of the Medicaid program. At issue was a part of the act that allowed Congress to offer additional Medicaid funding to states that complied with certain conditions laid out by Congress. The court did uphold this aspect of the act but stipulated that while Congress can offer new funding on conditions, it could not withhold existing funding for states' refusal to participate in the new program. Justice Roberts's key comment on the matter was, "Nothing in our opinion precludes Congress from offering funds under the ACA to expand the availability of healthcare, and requiring that states accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding."[22][23]

Not only did the court split 5-4 on the ultimate ruling, but the majority also split on which arguments were accepted in favor of the act's constitutionality. Justices Stephen Breyer, Ruth Bader Ginsburg, Elena Kagan and Sonia Sotomayor all accepted the case that the mandate was a legal use of Congress's powers under the Commerce Clause, however, Justice Roberts did not and only agreed that the mandate is legal as a tax. Justices Samuel Alito, Anthony Kennedy, Antonin Scalia and Clarence Thomas dissented with Justice Kennedy delivering their opinion saying, "The act before us here exceeds federal power both in mandating the purchase of health insurance and in denying non-consenting states all Medicaid funding."[22][23]

The court's full opinion can be found here.

Liberty University case reopened

Though the Supreme Court initially dismissed Liberty University, Inc. et al v. Geithner et al after its ruling in June, it has since reopened the case on the request of Liberty University. The court issued an order on November 26, 2012, agreeing that the lawsuit deserved a second look due to its unique challenges to the employer mandate and the contraceptive coverage mandate. As a result, the Fourth Circuit will give the case a second hearing, possibly by spring 2013, which could bring the act back before the Supreme Court.[19]

District of Columbia Court of Appeals

On November 7, 2011, a three judge panel from the District of Columbia Court of Appeals ruled on Seven-Sky et al. v. Holder et al., the appealed version of Mead et al. v. Holder et al. ruled on by the district court. The judges presiding were Judge Brett Kavanaugh, Senior Judge Harry Edwards, and Senior Judge Laurence H. Silberman. The court ruled 2-1 with Judge Edwards agreeing with Judge Silberman's majority opinion and Kavanaugh dissenting. In the ruling Judge Silberman acknowledged that federal authority asserted is large, but also necessary. He said, "The right to be free from federal regulation is not absolute, and yields to the imperative that Congress be free to forge national solutions to national problems, no matter how local -- or seemingly passive -- their individual origins." Judge Kavanaugh did not agree with Judge Silberman, however, and argued, citing the Anti-Injunction Act, that the court did not have jurisdiction to rule on the case because the law being contested does not come into effect until 2014.[24][25]

To view the court's ruling, please see here, a pdf of the decision retrieved from the court's website.

District of Columbia District Court

On February 22, Judge Gladys Kessler, of the Federal District Court for the District of Columbia, delivered the fifth federal court ruling on the constitutionality of the Affordable Care Act after hearing the case Mead et al. v. Holder et al. On the plaintiffs' claim that the 'individual mandate' violated the Commerce Clause, Judge Kessler ruled that, "making a choice is an affirmative action, whether one decides to do something or not do something," and, therefore, making the decision not to purchase health insurance qualifies as "economic activity." Part of Judge Kessler's reasoning behind this conclusion is that the unpaid portions of medical expenses incurred by uninsured individuals is shifted to individuals with health insurance which in turn substantially raises premiums. This led Judge Kessler to agree with act's findings that not having health insurance does affect the national market. This is notable because it is in direct contrast to previous judges that having ruled the mandate unconstitutional on the reasoning that not buying health insurance is "economic inactivity," thereby removing from under the control of the Commerce Clause.[26][27][28]

Judge Kessler also ruled on the plaintiffs' additional claim that the mandate violated their religious freedoms if they were choosing not to purchase health insurance because of their faith. Because plaintiffs making this claim must show that the mandate imposes a burden on their religious exercise, Judge Kessler rejected the claim noting that by making use of the act's option of opting out of the mandate and paying a fine individuals could avoid violating their faith.[28]

This ruling was appealed to the District of Columbia Court of Appeals.

Third Circuit

This court has not presided over any relevant cases at this time.

Middle District of Pennsylvania

On September 13, 2011, Judge Christopher Conner, of the Middle District of Pennsylvania, ruled on Barbara Goudy-Bachman, et al. v. United States Department of Health and Human Services, et al. Both sides int he case moved for summary judgement which was then granted by Judge Conner in favor of the plaintiffs. The lawsuit challenged the individual mandate on not only Commerce Clause grounds, but also the Takings Clause of the Fifth Amendment. In his ruling, Judge Conner determined that the individual mandate does exceed the power granted Congress under the Commerce Clause. Judge Conner also found that because the guaranteed issue and the pre-existing health condition reforms were so bound up in the individual mandate they must also be severed. However, Judge Conner did determine that these provision could be removed without invalidating the entire act.[29][30][31]

To view the court's ruling, please see here (dead link), a pdf of the decision retrieved from the court's website.

Fourth Circuit

On September 8, 2011, the United States Court of Appeals for the Fourth Circuit dismissed both cases brought before it regarding the ACA. First, the court dismissed the appeal of Commonwealth of Virginia v. Sebelius after finding that, since the mandate did not apply to the State itself, Virginia had no standing to challenge the law. The court then dismissed the appeal of Liberty University, Inc. et al v. Geithner et al saying that the individual mandate is a tax and that, due to the Anti-Injunction Act, it may not be challenged in court until the tax is collected.[32][18]

The court's opinion regarding the state's challenge may be found here and the opinion concerning Liberty University, here.

Eastern District of Virginia

On December 13, 2010, District Judge Henry Hudson ruled on Commonwealth of Virginia v. Sebelius. In the ruling, Judge Hudson sided with the plaintiff and judged that the individual mandate is unconstitutional saying, "An individual's personal decision to purchase -- or decline purchase -- (of) health insurance from a private provider is beyond the historical reach of the U.S. Constitution." Judge Hudson did, however, disagree with Attorney General Cuccinelli's assertion of the "essential, non-severable" nature of the provision and, instead, ruled that while the individual mandate must be cut, Congress is free to enforce the rest of the act. Judge Hudson also denied a request for injunctive relief by the state. This case was appealed to the Fourth Circuit.[33][34][35]

Western District of Virginia

Judge Norman Moon, on November 30, 2010, dismissed Liberty University, Inc. et al v. Geithner et al, therefore, siding with the defendants and upholding the constitutionality of the act. The plaintiffs included a non-profit organization, Liberty University, Inc., and five individuals. They argued that the act forces individuals to violate their religious belief because the law "does not protect against the mandatory insurance payments being used to fund abortion coverage." The plaintiffs further argued that the indiviudal mandate was an invalid regulation of economic inactivity.[36][18]

Judge Moon ruled on both these points. On the first, he noted that the act does not only state that no health insurance plan be required to cover abortion services, but that every state health insurance exchange must include at least one plan that does not provide coverage of non-excepted abortion services. Excepted services are defined as cases involving pregnancies that occur via rape or incest and cases where the pregnant woman's life is in danger. Judge Moon ruled on the second point saying, "by choosing to forgo insurance, plaintiffs are making an economic decision to try to pay for healthcare services later, out of pocket, rather than now, through the purchase of insurance."[36][37]

Judge Moon's decision was appealed to the Fourth Circuit. His opinion can be read here.

Sixth Circuit

As the first appellate court to rule on the act, the Sixth Circuit Court ruled against the plaintiffs in an appeal of Thomas More Law Center v. President of the United States from the Eastern District of Michigan. The case was brought before the circuit court on June 1, 2011, and was decided on June 29, with the court determining that the individual mandate was a valid exercise of the federal governments constitutional power.[38] The decision was made by the court as 2-1 with Judge Boyce Martin and Judge Jeffrey Sutton in the majority and Judge James Graham authoring the dissent.[39]

Eastern District of Michigan

A lawsuit was filed in the Michigan Eastern District Court by the Thomas More Law Center and 4 individuals on the day the act was passed. Judge George Steeh presided over the case and ruled against the plaintiffs' motion for preliminary injunction on October 7, 2010. In a ruling similar to Judge Moon's, of the Western District of Virginia, Judge Steeh asserted that no one can "opt out" of the healthcare market and that both the decision to purchase insurance or to pay out of pocket later is an economic decision. He further dismissed two of the plaintiffs' six claims, resulting in an appeal to the Sixth Circuit Court on October 22.[38][40]

Related news


  1. U.S. Government Printing Office page on the Patient Protection and Affordable Care Act
  2. Health Care Lawsuits listing of lawsuits
  3. 3.0 3.1 3.2 Healthcare Financial Management Association legal challenges page
  4. World Capitol Bureau "Oklahoma legislative panel to examine federal healthcare reform law," September 9, 2011 (dead link)
  5. Copy of the complaint via South Dakota Attorney General's website
  6. Original complaint, retrieved from Florida Attorney's General office website on the lawsuit
  7. BNO News "Arizona joins the multistate healthcare lawsuit," May 14, 2010
  8. Indiana Attorney General press release "Attorney General joins multi-state legal challenge to healthcare bill," March 29, 2010
  9. Bloomberg "Ohio, Wisconsin, Four More States Join Challenge to Obama Health Care," January 20, 2011
  10. Florida Attorney's General office website on the lawsuit
  11. Virginia Attorney's General office press release "Virginia Attorney General to file suit against federal government over passage of healthcare bill," March 22, 2010
  12. Letter from Virginia Attorney General to constituents "Letter from Virginia Attorney General Kenneth T. Cuccinelli"
  13. Copy of complaint, retrieved Virginia Attorney's General website (dead link)
  14. Oklahoma Attorney General press release "Oklahoma Attorney General-elect Will File Lawsuit Against Federal Health Care Reform Bill," January 7, 2011
  15. Copy of complaint, retrieved from Oklahoma Attorney's General website
  16. 16.0 16.1 Oklahoma Attorney General Press Release, "Attorney General’s Federalism Unit Files Amended Lawsuit against Affordable Care Act Implementation," September 19, 2012
  17.,"Oklahoma challenges ACA in lawsuit," September 20, 2012
  18. 18.0 18.1 18.2 "Liberty University, Inc. et al v. Geithner et al"
  19. 19.0 19.1,"Supreme Court Says Liberty University Case is Not Over," November 26, 2012
  20.,"Supreme Court orders Fourth Circuit to hear Liberty case," November 26, 2012
  21. CNN "Supreme Court takes up challenge to healthcare reform law," November 14, 2011
  22. 22.0 22.1 22.2 Live blog following the Supreme Court accessed on June 28, 2012
  23. 23.0 23.1 23.2 Associated Press "U.S. Supreme Court upholds individual mandate in Obama healthcare act," June 28, 2012
  24. CNN "Health care law held constitutional in latest appeals court ruling," November 8, 2011
  25. "Federal Appeals Court for DC Circuit upholds ACA’s individual mandate, November 8, 2011
  26. Examiner "Third federal judge rules healthcare law constitutional," March 2, 2011
  27. "Federal Judge In D.C. Upholds Health Care Reform, Says Some Arguments 'Ignore Reality'," February 22, 2011
  28. 28.0 28.1 "Update to Constitutional Challenges to Health Reform: Mead et al. v. Holder et al.," March 2, 2011
  29. "District court rules individual mandate unconstitutional," September 13, 2011
  30. "Federal Judge Says Health Care Reform Act's Individual Mandate Is Unconstitutional," September 13, 2011
  31. Court opinion, retrieved from Middle District of Pennsylvania website (dead link)
  32. HealthReformGPS, "Federal appeals court rules state of Virginia lacks standing in health reform challenge," September 8, 2011
  33. HealthReformGPS "District judge rules individual mandate unconstitutional," December 13, 2010
  34. CNN "Virginia judge rules healthcare mandate unconstitutional," December 13, 2010
  35. Court's opinion, retrieved from HealthReformGPS archives
  36. 36.0 36.1 CNN "Latest court ruling adds to conflict over healthcare reform," December 1, 2010
  37. Court's opinion, retrieved from archives
  38. 38.0 38.1 "Thomas More Law Center v. President of the United States"
  39. "Update: Legal Challenges to the Affordable Care Act," September 23, 2011
  40. "Legal Challenges to the Affordable Care Act," December 14, 2012