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SHOULD THE GOVERNMENT REQUIRE
all Americans to have health
insurance? While individual
Americans disagreed about
this question, the states and
the federal government also
disagreed about whether
Congress could force the states
to implement the Affordable
Care Act.F
OLLOWING PASSAGE OF THE 2010 AFFORDABLE CARE ACT (ACA),^1 26 states
sued the national government over the new law. Intended to provide health
care coverage to more than 30 million uninsured Americans, the law seemed to
these states to be an unconstitutional overreach of federal power: “the individual
mandate exceeds Congress’s enumerated powers, the Medicaid expansions
are unconstitutionally coercive, and the employer mandates impermissibly
interfere with state sovereignty.”^2 This is the federalism trifecta, hitting on
all three major themes concerning the balance of power among levels of
government: (1) Congress’s power to enact broad national legislation under
the Constitution’s commerce clause, (2) Congress’s power to compel states to
act through “coercive federalism,” and (3) states’ sovereign powers under the
Tenth and Eleventh Amendments.
Supporters of the law argued that standardizing these provisions across all
50 states was crucial to ensuring health care for all Americans because otherwise
millions of Americans would be unable to get health insurance. At present some
states do an excellent job of providing access to health care, but others do not.^3
As President Obama explained when signing the legislation, “we have now just
enshrined—as soon as I sign this bill—the core principle that everybody should
have some basic security when it comes to their health care.”^4 Furthermore, the
national law eliminates state-based insurance monopolies that drive up health
care costs; competition across state lines through the health insurance exchanges
mandated by the ACA will help keep health care costs lower.