Issues & AdvocacyFederal

The Court Upholds Health Reform: Now What?
By Andrew Goldberg, Assoc. AIA, Managing Director, Government Relations & Outreach

Few issues in recent memory have galvanized and polarized the public as much as the 2010 health care reform law. Reaction to the Supreme Court’s ruling last month to uphold most of the Affordable Care Act (ACA) was no different.

The law will affect virtually all Americans in some way as it begins to take effect in the coming years. Architects are no different; as consumers of health care, business owners who provide health insurance to employees, and in some cases the designers of health facilities, AIA members will be a part of this reform whether they choose to or not.

So what does it mean for architects? Over the coming months, the AIA will provide resources to members about the law and its implementation through articles, webinars and other media. First, though, here are a few observations now that the Supreme Court has made its decision.

What the Court Decided

The majority decision, written by Supreme Court Chief Justice Roberts and signed by Justices Breyer, Ginsberg, Kagan and Sotomayor, essentially addresses two key components of the law. The most controversial is the individual mandate, which requires that all Americans purchase insurance or pay money to the federal government. During oral arguments, the White House contended that the mandate was allowable under the Constitution’s Commerce Clause, which gives the federal government the power to regulate interstate commerce. Opponents of the law argued that this was an excessively broad reading of the Clause, and that if the government could compel citizens to purchase insurance, it could force you to buy almost anything.

The Court’s decision essentially rejected the administration’s argument that the mandate was allowed under the Commerce Clause. But they ruled that it is Constitutional per Congress’ power to levy taxes. In other words, paying a penalty to the federal treasury for not holding insurance is akin to a tax. Therefore, the individual mandate stands.

The second key point of contention is the law’s provision to expand the Medicaid health insurance program to cover more people. Under the ACA, states could have lost all their federal Medicaid money if they did not accept the law’s expansion. The Court ruled that this went too far because it in essence changed the rules of the game for states by threatening funding they had accepted before the program was expanded. Instead, the Court ruled, states can keep their existing funding if they choose not to comply with the expanded program, but would not be eligible for additional funding.

The Next Steps

House Republicans, who won a majority in 2010 fueled largely by opposition to the ACA, have made repealing the entire bill their top priority and have called on the Senate to follow suit. (The Senate, controlled by Democrats, has, unsurprisingly, not obliged.) House Republicans have scheduled another repeal vote for this week; it will pass, most assuredly, and will die in the Senate, most assuredly. So what next?

Former Massachusetts Gov. Mitt Romney, the presumptive GOP nominee, has expressed support for repealing the ACA if he wins the 2012 presidential election. Senate Republicans have said they will work to repeal the bill, too, should they win the majority. However, unless they capture a total of 60 seats – which is highly unlikely – they will not be able to overcome a filibuster by Democrats.

Republicans, however, believe that the Court’s deeming the mandate a tax may allow them to repeal it through a special process reserved for tax and budgetary matters, one that requires only 50 Senate votes to pass. Of course, if President Obama wins re-election, any talk of repeal will go away. As they say, elections matter.

Long-Term Implications

In ruling for the ACA, the Supreme Court nonetheless took some potentially significant steps that could limit federal policymaking on the states.

First, of course, was the Court’s rejection of the Commerce Clause argument in favor of the individual mandate. The Court’s opinion stated, “Construing the Commerce Clause to permit Congress to regulate individuals precisely because they are doing nothing would open a new and potentially vast domain to congressional authority.”

In essence, the Court is saying that the federal government cannot require people to engage in commerce if they choose not to do so. Could this have implications beyond health insurance, precluding for instance federal legislation that establishes a national building code that requires building owners to purchase and install certain materials or features? It is a hypothetical question, since there is no serious effort in the political arena to implement such a national code. But should that day come, the Court’s ruling on the ACA may play an impact on any challenge to it.

Second, in rejecting the ACA’s provision allowing the federal government to withhold all of a state's Medicaid funds if they do not agree to the law’s expansion, the Court may have set a precedent that could affect a range of federal policies. For example, although the federal government does not require states to enact seat belt laws, federal highway funding is made available to them on the condition they pass such laws. No seat belt law? No highway funding.

In the future, if Congress wants to impose additional requirements on states who accept transportation funding (such as requiring states to establish long-range planning for transportation systems), will the Court’s decision on ACA prevent Congress from denying that funding if the states reject the requirements? This could potentially limit one of the federal government’s most-used tools for getting states to adopt certain policies.

These aspects of the ruling are one of the reasons that conservatives, while disappointed that the Court upheld the ACA, hope that the decision will limit federal power in the years to come. Conversely, liberals, though pleased the ACA survived, are concerned that the ruling may limit policymaking from Washington down the road.

The AIA’s View

Numerous members have asked the AIA its position on the health care law, or the Court’s ruling. According to the AIA’s Public Policies and Position Statements, “The AIA supports governmental policies, programs, and administration that promote a fair tax code and business regulations that encourage the free enterprise system and the economic wellbeing of the American people, the U.S. construction industry, and the profession of architecture.”

So, does the ACA “promote a fair tax code and business regulations that encourage the free enterprise system and … economic wellbeing”? Or, does it inhibit them? It depends on whom you ask.

During one crucial period when the bill was being debated, the AIA government relations team received messages from some AIA members vowing to cancel their memberships if it endorsed the bill; and messages from other members threatening to quit the AIA if it did not endorse the bill. Surveys the AIA took of its members in that time period showed members almost evenly divided between more expansive single payer systems backed by liberals, market-based reform ideas espoused by conservatives, and several options in between. Architects are Democrats, Republicans, and Independents like the citizens they serve.

The AIA’s role will continue to be examining the details of the law and educating members about how it will impact them, providing the most objective and fact-based information available. Although we may not all agree on whether the law is a good thing, there is little disagreement it will affect everyone in the years to come.

Concerned members can connect and share with other architects, including those specializing in health facilities, in the AIA Knowledge Communities. Relevant communities are the Academy of Architecture for Health and Design for Aging. These special groups will likely have an understanding of the effects of this legislation on the built environment and their practice.

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