Department of Health and Human Services v. Florida Brief of Amici Curiae in Support of Petitioners

    No. 11-398

In  Th e

supreme Court of tlje flmteti States;

Department of Health and Human Services, e t al.,
Petitioners ,

v.

State of Florida, e t  al.

O n W rit of C ertio ra ri to  th e  U n ited  S ta te s  C ourt of 
A ppeals for th e  E leven th  C ircuit

BRIEF OF AMICI CURIAE 
NAACP LEGAL DEFENSE & EDUCATIONAL FUND, 

INC., AMERICAN CIVIL LIBERTIES UNION, AND THE 
LEADERSHIP CONFERENCE ON CIVIL 

AND HUMAN RIGHTS 
IN SUPPORT OF PETITIONERS 
(M inim um  Coverage Provision)

J ohn Payton 
Director- Counsel 

Debo P. Adegbile 
Elise C. Boddie 

Counsel o f  Record  
ReNika C. Moore 
Ria A. Tabacco 
NAACP Legal Defense 

& Educational Fund, Inc. 
99 Hudson S treet, 16th Floor 
New York, NY 10013 
(212) 965-2200 
eboddie@naacpldf. org

J oshua Civin 
NAACP Legal Defense 

& Educational Fund, Inc. 
1444 I S treet, NW, 10th Floor 
W ashington, DC 20005

Steven R. Shapiro 
American Civil Liberties 

Union Foundation 
125 Broad S treet 
New York, NY 10004

Lisa M. Bornstein 
Leadership Conference 

on Civil and Human Rights 
1629 K Street, NW 
W ashington, DC 20006



1

TABLE OF CO NTENTS

TABLE OF C O N T E N T S................................................... i

TABLE OF A U T H O R IT IE S ...... ...................................iii

IN TER ESTS OF A M IC I...................................................1

SUMMARY OF TH E A RG U M EN T..............................3

A R G U M E N T ..................................     5

I. The m inim um  coverage provision enhances
th e  ab ility  of ind iv iduals to p a rtic ip a te  in  
th e  economic, social, an d  civic life of our n a ­
tion, thereby  advancing  equal opportun ity  
an d  personal lib e r ty .....................................................5

A. The u n in su red  are  m ore likely to
experience conditions th a t  inh ib it th e  
quality  of l i f e . ....................................................   6

B. The m inim um  coverage provision
prom otes equal o p p o rtu n ity ......................   9

C. The ab ility  to self-insure is not an a lo ­
gous to any  liberty  in te re s ts  recog­
nized by th is  C o u r t ......................................... 12

1. The provision im poses m inim al
b u rdens on lib e rty ................................... 14

2. U nder th e  C ourt’s Commerce
C lause ju risp rudence, ind iv iduals 
m ust som etim es yield economic 
liberty  to advance th e  collective 
good.............................................................. 16

II. The N ecessary  and  P roper C lause fu r th e r
supports  th e  constitu tiona lity  of the  
m inim um  coverage provision.............................. 21



11

CONCLUSIO N 24



I l l

TABLE OF A U TH O RITIES 

C ases

Bond v. United States, 131 S. Ct. 2355 (2011)...... 13

Bryan u. Koch, 627 F.2d 612 (2d Cir. 1980)............. 1

Cruzan v. Director, Missouri Department of 
Health, 497 U.S. 261 (1990).............................. 14-15

Delaware v. Prouse, 440 U.S. 648 (1 9 7 9 ).........  15-16

Employment Division v. Smith, 494 U.S. 872 
(1 9 9 0 )............................................................................... 20

Garcia v. Vanguard Car Rental USA, Inc., 540 
F .3d 1242 (11th Cir. 2 0 0 8 )..................................   16

Gonzales v. Raich, 545 U.S. 1 (2005)........... 18-19, 22

Griswold v. Connecticut, 381 U.S. 479 (1965)....... 15

Heart of Atlanta Motel, Inc. v. United States,
379 U.S. 241 (1 9 6 4 )...................................................  11

Hosanna-Tabor Evangelical Lutheran Church
& School v. EEOC , No. 10-553, 556 U .S .___
(2 0 1 2 )...............................................................................20

Jacobson v. Massachusetts, 197 U.S. 11 (1905).... 15

Katzenbach v. McClung, 379 U.S. 294 (1964)........ 11

Lawrence v. Texas, 539 U.S. 558 (2003)........... 11, 15

Linton v. Commissioner of Health & 
Environment, 65 F.3d 508 (6th  Cir. 1995)........... 1

Lochner v. New York, 198 U.S. 45 (1905)...............  13

McCulloch v. Maryland, 4 W heat. 316 (1 8 1 9 )......21

Moore v. City of East Cleveland, 431 U.S. 494 
(1977) 15



IV

Mussington v. St. Luke’s-Roosevelt Hospital 
Center, 824 F. Supp. 427 (S.D.N.Y. 1 9 9 3 )...........

NLRB v. Jones & Laughlin Steel Corp., 301 
U.S. 1 (1937).............. ..........................................  14,

Ophthalmic Mutual Insurance Co. v. Musser, 
143 F.3d 1062 (7th  Cir. 1 9 9 8 )................................

Parents Involved in Community Schools v. 
Seattle School District No. 1, 551 U.S. 701 
(2 0 0 7 )..............................................................................

Planned Parenthood of Southeastern 
Pennsylvania v. Casey, 505 U.S. 833 (1992)......

Rackley v. Board of Trustees of Orangeburg 
Regional Hospital, 238 F. Supp. 512 
(E.D.S.C. 1965).............................................................

Rochin v. California, 342 U.S. 165 (1952)..............

Sabri v. United States, 541 U.S. 600 (2004)...........

Seven-Sky v. Holder, 661 F .3d 1 (D.C. Cir. 
2011) ..............................................................................................

Sim kins v. Moses H. Cone Memorial Hospital, 
323 F .2d 959 (4th  Cir. 1963 )....................................

Thomas More Law Center v. Obama, 651 F.3d 
529 (6th  Cir. 2011).............................................. 16,

United States v. Comstock, 130 S. Ct. 1949 
(2 0 1 0 ).................................................................21, 23-

United States v. Darby, 312 U.S. 100 (1941).........

United States v. Lee, 455 U.S. 252 (1982)........  19-

United States v. Lopez, 514 U.S. 549 (1 9 9 5 ).........

United States v. Wrightwood Dairy Co., 315

. 1

19

16

11

15

,. 1

15

23

22

,. 1

18

■24

19

20

23



V

U.S. 110 (1942)............................................................ 23

Washington u. Glucksberg, 521 U.S. 702 
(1 9 9 7 )...................   14-15

West Coast Hotel Co. v. Parrish, 300 U.S. 379 
(1 9 3 7 ).......................................................................  13-14

Wickard u. Filburn, 317 U.S. I l l  (1942)........... 16-19

F ed era l S ta tu te s

H ealth  C are and  E ducation  Reconciliation Act 
of 2010, Pub. L. No. 111-152, 124 S ta t. 1029
(2 0 1 0 )................................................................................. 3

P a tie n t P ro tection  an d  Affordable C are Act,
Pub. L. No. 111-148, 124 S ta t. 119 (2010).............3

26 U.S.C. § 5000A ............................................................. 4

26 U.S.C. § 5000A (f)(l)......................   14

42 U.S.C. § 300gg ............................................................ 21

42 U.S.C. § 3 0 0 g g -l...........................................................9

42 U.S.C. § 300gg-l(a)....................................................21

42 U.S.C. § 300gg-3(a)....................................................21

42 U.S.C. § 18091(a)(2)(A)..............................................4

42 U.S.C. § 18091(a)(2)(E)..............................................8

42 U.S.C. § 18091(a)(2)(F).................................. 8-9, 22

42 U.S.C. § 18091(a)(2)(G )...............................................7

42 U.S.C. § 18091(a)(2)( I ) .......................................9, 22



VI

C ou rt F ilin g s

C onsent D ecree, Terry v. Methodist Hospital 
of Gary, Nos. H-76-373, H-77-154 (N.D. Ind.
Ju n e  8, 1 9 7 9 )................................................................. 1

O th er A u th o r it ie s

Jam e s  A. B aker III In s titu te  for Public Policy 
of Rice U niversity , The Economic Impact of 
Uninsured Children on America (H ouston,
Tex.), Ju n e  2009......................................................... 7-8

Robin A. Cohen e t al., Health Insurance Cov­
erage: Early Release of Estimates from the 
National Health Interview Survey, 2010
(N ational C en ter for H ealth  S tatistics),
Ju n e  2011...........................................................................7

Jack  H adley, Sicker and Poorer: The Conse­
quences of Being Uninsured (K aiser Fam ily  
F oundation , W ash., D.C.), M ay 10, 2002 ................7

C atherine  H offm an & J u lia  P arad ise , Health 
Insurance and Access to Health in the 
United States, 1136 A nnals N.Y. Acad. Sci.
149 (2 0 0 8 )......................................................................... 8

In s titu te  of M edicine, C om m ittee on th e  Con­
sequences of U n insurance , Coverage M at­
ters: Insurance and Health Care (2001).......  10-11

In s titu te  of M edicine, C om m ittee on th e  Con­
sequences of U ninsu rance , Health Insur­
ance Is a Family Matter (2002)..............................6-8

K aiser Com m ission on M edicaid and  th e  U n ­
insu red , The Uninsured: A  Primer, Key 
Facts About Americans Without Health In-



surance (K aiser Fam ily  F oundation , W ash., 
D.C.), Oct. 2007...................................................6-7, 10

N eil S. Siegel, Four Constitutional Limits that 
the M inimum Coverage Provision Respects,
27 Const. Com m ent. 591 (2011)...............................4

K ris ten  S u thers , Evaluating the Economic 
Causes and Consequences of Racial and 
Ethnic Health Disparities (Am erican Public 
H ealth  A ssociation, W ash., D.C.), Nov.
2008 ......................................................................... 8, 10

U.N. C om m ittee on the  E lim ination  of R acial 
D iscrim ination, C onsideration  of R eports 
S ubm itted  by S ta tes  P a rtie s  u n d e r A rticle 9 
of th e  Convention, Concluding O bserva­
tions of th e  C om m ittee on th e  E lim ination  
of R acial D iscrim ination , U n ited  S ta tes  of 
A m erica (May 2, 2008), available at
http ://w w w . sta te , gov/ docum ents/organizatio  
n/107361.pdf (last v is ited  Ja n . 10, 2012).

vii

10

http://www


1

IN T E R E ST S OF A M IC I1

The NAACP Legal D efense & E ducational Fund, 
Inc. (LDF) is a  non-profit legal o rgan ization  th a t  for 
m ore th a n  seven decades h as  helped  A frican A m eri­
cans secure th e ir  civil and  constitu tiona l righ ts. 
T hroughout its h istory , LD F h as  w orked to support 
an d  provide equal tre a tm e n t and  h igh-quality  m edi­
cal services, care, an d  opportun ities to A frican 
A m ericans. E.g., Linton v. Comm’r of Health & 
E nv’t, 65 F.3d 508 (6th  Cir. 1995) (preservation  of 
M edicaid-certified h osp ita l and  n u rs in g  hom e beds to 
p rev en t eviction of p a tie n ts  in  favor of ad m ittin g  
m ore rem u n era tiv e  p riva te -pay  individuals); Bryan 
v. Koch, 627 F.2d 612 (2d Cir. 1980) (challenge to 
closure of m unicipal hosp ita l serv ing  inner-city  re s i­
dents); Simkins v. Moses H. Cone M em’l Hosp., 323 
F.2d 959 (4th  Cir. 1963) (adm ission of African- 
A m erican physician  to hosp ita l staff); Mussington v. 
St. Luke’s-Roosevelt Hosp. Ctr., 824 F. Supp. 427 
(S.D.N.Y. 1993) (relocation of services from  inner- 
city b ran ch  of m erged hosp ita l entity); Rackley u. Bd. 
of Trs. of Orangeburg Reg’l Hosp., 238 F. Supp. 512 
(E.D.S.C. 1965) (desegregation of hosp ita l w ards); 
C onsent Decree, Terry v. Methodist Hosp. of Gary, 
Nos. H-76-373, H-77-154 (N.D. Ind. Ju n e  8, 1979) 
(p lanned relocation of u rb an  hosp ita l services from 
inner-city  com m unity). LD F h as  a su b stan tia l in te r ­

1 P u rsu an t to Suprem e Court Rule 37.6, counsel for amici 
s ta te  th a t  no counsel for a party  au thored  th is  brief in  whole or 
in part, and th a t no person other th an  amici, their members, or 
th e ir counsel made a m onetary contribution to the preparation  
or subm ission of th is brief. The parties have filed b lanket con­
sen t le tters  w ith the Clerk of the Court p u rsu an t to Suprem e 
Court Rule 37.3.



2

est in  th is  case because of its  con tinu ing  com m it­
m en t to  p rom oting  opportun ity  for A frican A m eri­
cans, includ ing  access to affordable h e a lth  in su ran ce  
an d  h e a lth  care.

The A m erican  Civil L iberties  U nion (ACLU) is a 
nationw ide, n o n p a rtisan , nonprofit o rgan ization  
w ith  m ore th a n  500,000 m em bers dedicated  to th e  
princip les of lib e rty  an d  equality  em bodied in  th e  
C o n stitu tion  an d  th is  n a tio n ’s civil rig h ts  laws. 
Since i t  w as founded in  1920, th e  ACLU h as  
app eared  before th is  C ourt in  num erous cases, bo th  
as d irect counsel and  as am icus curiae. The ACLU 
h as  a su b s ta n tia l in te re s t in  th e  p roper reso lu tion  of 
th is  case because of its  p o ten tia l im pact on th e  ab il­
ity  of m illions of u n in su red  A m ericans to p a rtic ip a te  
m ore fully  in  th e  economic, political, an d  social life of 
th e  N ation.

The L eadersh ip  Conference on Civil an d  H um an  
R ights is a d iverse coalition of m ore th a n  200 
n a tio n a l o rgan izations charged  w ith  prom oting an d  
p ro tec ting  th e  rig h ts  of all persons in  th e  U nited  
S ta tes . The L eadersh ip  Conference w as founded in  
1950 by A. Philip  R andolph, h ead  of th e  B rotherhood 
of Sleeping C ar P orters; Roy W ilkins of th e  NAACP; 
an d  A rnold A ronson, a lead er of th e  N ational Jew ish  
C om m unity  R elations A dvisory Council. The L ead ­
ersh ip  Conference w orks to bu ild  an  A m erica th a t  is 
as good as its  ideals, and  tow ard  th is  end, supports  
th e  au th o rity  of C ongress to en ac t legislation, such 
as th e  P a tie n t P ro tection  an d  Affordable C are Act, 
w hich provides for th e  general w elfare of th e  nation . 
Access to qua lity  h e a lth  care is a  fu n d am en ta l civil 
an d  h u m a n  righ t, b u t th e  c u rren t system  of h ea lth  
care in  th e  U n ited  S ta tes  denies th is  rig h t to th e



3

m ost vu lnerab le  segm ents of society, including low- 
incom e fam ilies, people of color, women, seniors, and  
people w ith  d isabilities. By add ressing  th e  huge d is­
p a ritie s  in  bo th  access to an d  qua lity  of care, the  
P a tie n t P ro tection  an d  Affordable C are Act tak es  a 
m om entous step  tow ard  en su ring  th a t  all A m ericans 
can benefit from  affordable, h igh-quality  h e a lth  care.

SUM M ARY OF THE ARG UM ENT

In  our m odern, in teg ra ted , and  dynam ic h ea lth  
care system , personal choices have consequences 
th a t  ex tend  fa r beyond th e  indiv idual. The economic 
decision to forego h ea lth  insu rance , therefore, is not 
n eu tra l. R ather, such a decision, w hen aggregated  
across our n a tio n a l population, both  lim its th e  p e r­
sonal liberty  of o thers to  choose h e a lth  in su rance  
an d  h as  th e  effect of reinforcing h a rsh  economic and  
social d isparities  th a t  th re a te n  our country’s dem oc­
ra tic  foundation  and  th e  cohesion of our society.

The m inim um  essen tia l coverage provision of the  
P a tie n t P ro tection  and  Affordable C are Act (“ACA” 
or “th e  Affordable C are Act”), Pub. L. No. 111-148, 
124 S ta t. 119 (2010),2 prom otes opportun ity  for m il­
lions of un in su red  persons to p a rtic ip a te  in  th e  life of 
our nation . I t  achieves th is  objective by m aking  
h e a lth  in su ran ce  and, u ltim ate ly , h e a lth  care itse lf 
m ore affordable. This, in  tu rn , a llev iates th e  severe 
financial b u rdens th a t  fall on th e  u n insu red , w hich 
have a d isproportionate  negative im pact on d isad ­
van tag ed  populations. By reducing  th e  exclusionary, 
ha rm fu l effects of th e  c u rren t system , th e  m inim um

2 As am ended by the H ealth  Care and Education Recon­
ciliation Act of 2010, Pub. L. No. 111-152, 124 S tat. 1029 
(2010).



4

coverage provision, 26 U.S.C. § 5000A -  th e  co rner­
stone of ACA -  enab les covered persons to lead  
h ea lth ie r , freer, an d  m ore productive lives, th e reb y  
advancing  th e  tw in  goals of liberty  an d  equal oppor­
tu n ity . R espondents, therefore , go too fa r in  su g g est­
ing th a t  th e  provision tren ch es  on ind iv idual liberty  
in  w ays th a t  requ ire  th is  C ourt to cu rta il federal 
power.

Amici support th e  position  of th e  U n ited  S ta te s  
th a t  th e  E leven th  C ircuit e rred  in  its  analy sis  of 
C ongress’s pow er to enac t th e  m in im um  coverage 
provision u n d e r bo th  th e  Com m erce and  N ecessary  
an d  P roper C lauses. P et. Br. 17-20. C ongress acted  
well w ith in  its con stitu tio n a l a u th o rity  in  seeking  to 
reg u la te  “‘economic an d  financial decisions about 
how an d  w hen h e a lth  care is pa id  for, an d  w hen 
h e a lth  in su ran ce  is p u rch ased ”3 in  o rder to  p rev en t 
th e  severe economic an d  social u p h eav a l th a t  occurs 
w hen significant portions of th e  n a tio n a l population  
a re  u n in su re d .4 See 42 U.S.C. § 18091(a)(2)(A).

Amici w rite  sep ara te ly  to ad d ress  th e  E leven th  
C ircu it’s m isch arac teriza tio n  of th e  liberty  in te re s ts  
th a t  a re  a t  s tak e  in  th is  case an d  to em phasize th e  
positive role th e  m in im um  coverage provision plays 
in  advancing  equal opportunity . Amici add itionally  
dem o n stra te  th a t  th e  N ecessary  an d  P roper C lause

3 See Neil S. Siegel, Four C onstitutional L im its that the 
M inim um  Coverage Provision Respects, 27 Const. Comment. 
591, 596-99 (2011) (describing economic n a tu re  of decision to 
self-insure).

4 In  2009, the  num ber of un insured  persons to taled  ap­
proxim ately 50 million. Pet. Br. 7.



5

supports  C ongress’s au th o rity  to enact th e  m inim um  
coverage provision.

ARG UM ENT

I. T h e m in im u m  c o v er a g e  p r o v is io n  e n h a n c e s  
th e  a b ility  o f  in d iv id u a ls  to  p a r tic ip a te  in  
th e  e co n o m ic , so c ia l, a n d  c iv ic  life  o f  ou r  
n a tio n , th e r e b y  a d v a n c in g  eq u a l o p p o rtu ­
n ity  a n d  p e r so n a l lib er ty .

Across our country, u n in su red  persons experience 
significant h a rd sh ip  th a t  h as  a profound cum ulative 
im pact on our nation . B ecause th ey  a re  less likely to 
ob ta in  adequate , stab le  h e a lth  care, th e  u n in su red  
suffer m any  lost opportun ities, w hich depresses both  
th e  q u a lity  an d  th e  longevity of th e ir  lives. These 
b u rd en s are  d isproportionately  borne by rac ial and  
ethn ic  m inorities, lower-incom e persons, and  o ther 
d isadvan taged  persons. For m any indiv iduals, being 
u n in su red  is not a  choice, b u t ra th e r  is a consequence 
th a t  is im posed on th em  due to c ircum stances 
largely  beyond th e ir  control. See Pet. Br. 6 (“The 
coverage gaps [the un insured] experience re su lt for 
th e  m ost p a r t from  th e  h igh  cost of in su rance  and  
em ploym ent changes — not a belief th a t  coverage is 
unnecessary .”).

Yet, a lthough  th ey  lack steady  access to h ea lth  
care, u n in su red  persons a re  not com pletely p re ­
cluded from  using  m edical services. Id. a t 7. U n ­
foreseen crises can lead  to costly em ergency room 
v isits  an d  hosp ita liza tions th a t, w hile not covered by 
th e  un insu red , a re  still paid  for by th e  h ea lth  care 
system  as a whole, even tually  leading  to h igher 
in su ran ce  prem ium s for everyone. Id. a t 7-8. By re ­
qu iring  non-exem pt ind iv iduals to b ear some of the



6

cost of th e ir  o therw ise  un co m p en sa ted 5 care, th e  
m in im um  coverage provision h as  th e  effect of low er­
ing th e  cost of h e a lth  in su ran ce  an d  m ak ing  h e a lth  
care m ore affordable an d  accessible. I t  is an  e ssen ­
tia l com ponent of th e  A ffordable C are A ct’s com pre­
hensive regu la to ry  fram ew ork, id. a t 24-32, th a t  
u ltim a te ly  helps to p ro tec t an d  to im prove th e  lives 
of u n in su red  persons an d  to reduce th e  severe in eq ­
u ities  of our c u rren t system .

A. T h e u n in su r e d  are  m o re  lik e ly  to  e x p e r i­
e n c e  c o n d it io n s  th a t  in h ib it  th e  q u a lity  
o f  life .

From  cradle to grave, lack  of in su ran ce  can (and 
often does) re su lt in  life-inh ib iting  an d  personally  
catastroph ic  conditions th a t  th re a te n  th e  very  core of 
a person’s ab ility  to function. B ecause of th e  h igh  
cost of h e a lth  care u n d e r our cu rre n t system , th e  u n ­
in su red  m u st often choose betw een  paying  directly  
for h e a lth  care services an d  o ther, basic life necessi­
ties. K aiser Com m ’n on M edicaid an d  th e  U n in ­
sured , The Uninsured: A  Primer, Key Facts About 
Americans Without Health Insurance (here inafte r 
Primer on Uninsured) (K aiser F am ily  Found., 
W ash., D.C.), Oct. 2007, a t  9. Faced w ith  th ese  diffi­
cu lt tradeoffs, th e  u n in su red  a re  fa r m ore likely to 
accum ulate  significant deb t an d  to  experience the  
life-a ltering  effects of severe financial hard sh ip . See 
In st, of Med., Comm, on th e  Consequences of U n in ­
surance, Health Insurance Is a Family Matter (here­
in a fte r Family Matter) 77 (2002). Those who cannot

5 “U ncom pensated care” refers to “care received by u n in ­
sured patien ts bu t not paid for by them  or by a th ird  party  on 
th e ir behalf.” Pet. Br. 8.



7

en dure  th e  financial bu rd en s of non-covered h ea lth  
care services m ay sim ply decide to forego them .

I t  is unsu rp ris in g , therefore, th a t  th e  u n in su red  
have  h ig h er ra te s  of illness, see Primer on Uninsured 
a t 7-8, and  suffer th e  effects of lost educational, em ­
ploym ent, an d  o th er social an d  civic opportun ities. 
O ver tim e, th is  lost h u m an  cap ita l degrades th e ir  
lives an d  iso lates th em  from  th e  re s t of th e  popu la­
tion. As m ultip le  stud ies show, those w ithou t in s u r­
ance often lead  chaotic lives. They are  less likely to 
receive p reven ta tive  care for tre a tab le  illnesses, 
re su ltin g  in  serious an d  even life-th rea ten ing  condi­
tions. See Family Matter a t 87-88; Jack  H adley, 
Sicker and Poorer: The Consequences of Being Unin­
sured (here inafte r Sicker and Poorer) (K aiser Fam ily  
Found., W ash., D.C.), M ay 10, 2002, a t 5-9. C hildren  
w ith  u n tre a te d  h e a lth  problem s a re  less likely to  a t ­
ten d  and  to perform  well in  school. Family Matter a t 
122-24; Sicker and Poorer a t 15. Being u n in su red  
also correla tes w ith  o ther poor educational outcom es, 
such as failing  to g rad u a te  from  high school or to 
enroll in  college. See Robin A. Cohen e t al., Health 
Insurance Coverage: Early Release of Estimates from 
the National Health Interview Survey, 2010 (here in ­
a fte r Health Insurance Coverage) (N at’l C tr. for 
H ea lth  S tatistics), Ju n e  2011, a t  4; Primer on Unin­
sured a t 5. The u n in su red  often am ass significant 
debt as a  re su lt of unforeseen m edical expenses, 
lead ing  to a  dow nw ard, destab ilizing  financial sp iral, 
including  poor credit, Primer on Uninsured a t 9; 
bankrup tcy , 42 U.S.C. § 18091(a)(2)(G); lost wages; 
lower an n u a l earn ings, Sicker and Poorer a t 13-14; 
an d  unem ploym ent, Jam es  A. B aker III In st, for 
Public Policy of Rice Univ., The Economic Impact of



8

Uninsured Children on America (H ouston, Tex.), 
Ju n e  2009, a t  5-6. These consequences a re  often 
cum ulative  an d  se lf-perpetuating  an d  can  create  a 
vicious cycle of poor h e a lth  an d  reduced  opportun ity  
th a t  fu r th e r  d im in ishes th e  q u a lity  of life. See Fam ­
ily Matter a t  76; see also 42 U.S.C. § 18091(a)(2)(E); 
C ath erin e  H offm an & J u lia  P arad ise , Health Insur­
ance and Access to Health in the United States, 1136 
A nnals N.Y. Acad. Sci. 149, 150-51 (2008); K risten  
S u th ers , Evaluating the Economic Causes and Con­
sequences of Racial and Ethnic Health Disparities 
(h e re in a fte r Racial and Ethnic Disparities) (Am. 
Pub. H ea lth  A ss’n, W ash., D.C.), Nov. 2008, a t 2.

C ongress reasonab ly  concluded th a t  low ering the  
cost of h e a lth  in su ran ce  w as v ita l to th e  s tre n g th  
an d  stab ility  of our na tion . Pet. App. 216a (M arcus, 
J ., d issen ting) (“Congress h a s  w ide regu la to ry  la t i­
tu d e  to ad d ress  th e  ex ten t of f inancial risk -tak in g  in 
th e  h e a lth  care services m arke t, w hich in  its  view is 
a th re a t  to a n a tio n a l m a rk e t.” (citations an d  in te r ­
n a l quo ta tion  m arks om itted)). The m in im um  cover­
age provision is th e  cornerstone of C ongress’s efforts 
to reduce h e a lth  in su ran ce  costs. I t  accom plishes 
th is  objective by reg u la tin g  “how h e a lth  care con­
sum ption  is financed,” Pet. Br. 17, in  o rder to d is ru p t 
th e  cost-shifting  th a t  occurs w hen u n in su red  in d i­
v iduals use  uncom pensated  care. As noted  above, 
because m any  u n in su red  a re  unab le  to pay  in  full for 
th e  services th ey  receive, m edical p roviders sh ift th e  
cost of th e ir  uncom pensated  services — to ta lin g  $43 
billion in  2008 -  to in su re rs  in  th e  form  of h igher 
charges. Pet. App. 11a. In su re rs  th e n  sh ift these  
costs to in su red  persons in  th e  form  of h igher p rem i­
um s. Id. a t  l la -1 2 a ; see also 42 U.S.C.



9

§ 18091(a)(2)(F) (congressional find ing  th a t  average 
p rem ium  increases for in su red  fam ilies by m ore th a n  
$1000 annually ). By req u irin g  ind iv iduals to p u r­
chase in su ran ce  (or risk  in cu rrin g  a financial p en ­
alty), th e  m inim um  coverage provision elim inates 
th is  cost-shifting  problem , thereby  low ering in su r­
ance prem ium s for all. Pet. App. 11a-12a (citing 42 
U.S.C. § 18091(a)(2)(F)).

The m inim um  coverage provision also helps to ef­
fec tuate  th e  g u a ran teed  issue provision of th e  Act, 
42 U.S.C. § 300gg-l, w hich requ ires  in su re rs  to 
enro ll a ll app lican ts. In  th e  absence of a m inim um  
coverage requ irem en t, th e  g u a ran teed  issue provi­
sion would reinforce th e  incentive for h ea lth y  people 
to w ait u n til th ey  w ere sick to ob ta in  h e a lth  in su r­
ance. This would increase th e  u n d erw ritin g  and  
ad m in is tra tiv e  costs th a t  have historically  con trib ­
u ted  to h igh  prem ium s. Congress ra tiona lly  con­
cluded th a t  such a re su lt would f ru s tra te  its  reform  
effort an d  included th e  m inim um  coverage provision 
to help  ensu re  th a t  in su rance  would be affordable. 
See id. § 18091(a)(2)(I). I t did  so based  on th e  rec­

ognition th a t  s teady  access to h e a lth  care enables 
ind iv iduals to lead  ordered, stable, and  productive 
lives — th e  effects of w hich benefit our en tire  country. 
The provision enhances indiv idual liberty  to p a rtic i­
p a te  in  and  contribute  to th e  life of our nation, 
alongside those who already  have insurance.

B. T h e m in im u m  co v er a g e  p r o v is io n  
p ro m o tes  eq u a l o p p o rtu n ity .

The b u rdens of costly h e a lth  care a re  not d is trib ­
u ted  evenly. R ather, they  fall d isproportionately  on 
d isadvan taged  populations w hich a re  m ore likely to



10

experience h ig h er ra te s  of unem ploym ent, to have 
jobs th a t  do no t offer h e a lth  in su rance , an d  to have 
low er incom es th a t  p u t h ig h er in su ran ce  p rem ium s 
ou t of th e ir  financial reach. See Primer on Unin­
sured a t  4-5.

A lthough m ore th a n  h a lf  of all u n in su red  persons 
a re  non-H ispanic w hites, In s t, of M ed., Comm, on 
th e  C onsequences of U n insu rance , Coverage Matters: 
Insurance and Health Care (here in a fte r Coverage 
Matters) 12 (2001), rac ia l m inorities a re  “m uch m ore 
likely  to be u n in su red  th a n  w hites.”6 Primer on Un­
insured a t  5. L atinos a re  th e  m ost likely  to be u n in ­
sured , followed by A frican A m ericans. Coverage 
Matters a t  12. These rac ia l an d  e thn ic  d isparities  
p red ic tab ly  lead  to h ig h er m o rta lity  ra te s  com pared 
to th e  in su red  population. See Racial and Ethnic 
Disparities a t  2. O th er associated  effects of being 
u n in su red  -  including  th e  prolonged d u ra tio n  of o th ­
erw ise tre a ta b le  illnesses, depressed  educational 
outcom es, an d  few er em ploym ent opportun ities  — are  
m ore likely  to affect rac ia l m inorities. Id. a t  2-4.7

6 In  a recent periodic review, the U nited  N ations Commit­
tee on the E lim ination of Racial D iscrim ination noted its con­
cern “th a t a large num ber of persons belonging to racial, ethnic 
and national m inorities still rem ain  w ithout h ea lth  insurance 
and face num erous obstacles to access to adequate hea lth  care 
and  services.” U.N. Comm, on the E lim ination of Racial D is­
crim ination, C onsideration of Reports Subm itted by S ta tes P a r­
ties u nder Art. 9 of the  Convention, Concluding O bservations of 
the Comm, on the E lim ination of Racial D iscrim ination, U nited 
S ta tes of Am erica !' 32 (May 2, 2008), available at 
http://w w w .state.gov/docum ents/organization/107361.pdf (last 
visited Jan . 10, 2012).

7 Gender is also correlated w ith less stable forms of in su r­
ance. A lthough m en in  general are  more likely to be uninsured,

http://www.state.gov/documents/organization/107361.pdf


11

By fac ilita ting  affordable h e a lth  care, th e  m in i­
m um  coverage provision in teg ra te s  th e  u n in su red  
m ore fully in to  th e  life of our n a tion  an d  helps them  
to p a rtic ip a te  on a m ore equal footing w ith  th e  re s t 
of society. The provision therefo re  prom otes equal 
opportunity , in  add ition  to personal liberty . See 
Lawrence v. Texas, 539 U.S. 558, 575 (2003) (observ­
ing th a t  equal protection an d  “su b stan tiv e  g u a ran tee  
of liberty  a re  linked  in  im p o rtan t respects”). 
C ongress’s desire  to prom ote equal opportunity , of 
course, is not dispositive of th e  question  p resen ted  in 
th is  case. B ut in  exercising its  Com m erce C lause 
powers, C ongress certa in ly  m ay consider th e  im pact 
such leg islation  will have on those who a re  otherw ise 
d isadvan taged  by m ark e t d isto rtions beyond th e ir  
control. See, e.g., Parents Involved in Cmty. Schs. v. 
Seattle Sch. Dist. No. 1, 551 U.S. 701, 787-88 (2007) 
(Kennedy, J ., concurring  in  p a r t an d  concurring in 
judgm ent) (noting “th e  leg itim ate  in te re s t govern­
m en t h as  in ensu ring  all people have equal opportu ­
n ity  regard less  of th e ir  race”); Katzenbach v. 
McClung, 379 U.S. 294, 299-300 (1964); Heart of A t­
lanta Motel, Inc. v. United States, 379 U.S. 241, 257 
(1964).

“women are more likely to obtain coverage through individual 
policies and public program s” and, therefore, are more likely to 
experience gaps in  coverage. Coverage M atters a t 12. For a 
fuller discussion of the  difficulties women have in obtaining 
and  m ain tain ing  hea lth  insurance, see Amici Br. of N ational 
Women’s Law C enter et al.



12

C. T h e a b ility  to  se lf - in su r e  is  n o t a n a lo g o u s  
to  a n y  lib e r ty  in te r e s ts  r e c o g n iz e d  b y  
th is  C ourt.

In  re jecting  C ongress’s au th o rity  to enac t th e  
m in im um  coverage provision, th e  court of appeals 
suggested  th a t  ind iv idual preferences to self-insure 
should  override C ongress’s decision to requ ire  near- 
u n iv e rsa l8 in su ran ce  coverage. The E leven th  C ircuit 
em phasized  th e  liberty  of ind iv iduals to forego 
h e a lth  in su rance . B u t it  d isregarded  th e  co u n ter­
vailing  lib e rty  in te re s ts  of ind iv iduals w hose access 
to  h e a lth  in su ran ce  will be constra ined  in  the  
absence of such a  provision due to cost-shifting  from  
th e  u n in su red  to th e  insu red . This dynam ic h as  the  
effect of p lacing  affordable, s tab le  h e a lth  care out of 
financial reach  for m any people. Pet. App. 11a (de­
scrib ing inab ility  of some u n in su re d  to pu rchase  cov­
erage “because of h igher p rem ium s”).

R espondents abandoned  th e ir  su b stan tiv e  due 
process claim  on appeal below. Id. a t  112a n.93. 
Therefore, th e  question  w h e th er th e  m in im um  cov­
erage provision u n co nstitu tiona lly  in fringes th e ir  
lib e rty  in te re s ts  w as no t squarely  before th e  court of 
appeals. See id. N onetheless, th e  E leven th  C ircu it’s 
concerns about th e  provision’s effects on liberty

8 The s ta tu te  contains several exem ptions to the m inim um  
coverage provision. These include exem ptions on the  basis of 
religion; for persons not lawfully p resen t in  the  country; for in ­
carcerated  persons; for those who fail to m eet certain  threshold 
income requirem ents; for those who have short-term  gaps in 
th e ir coverage; for “hardsh ip” cases, as determ ined by the 
D epartm ent of H ealth  and H um an Services; and for m em bers 
of Native Am erican tribes. Pet. App. 43a.



13

pla in ly  an im a ted  its  conclusion th a t  Congress 
“depart[ed] from  com m erce power norm s.” Id. a t 
112a. The court of appeals objected th a t  th e  p rovi­
sion leaves persons “no choice” b u t “to purchase  in ­
su rance ,” w hich “s trik es  a t  th e  h e a r t  of w h e th er 
C ongress h as  acted  w ith in  its  enu m era ted  pow er.” 
Id. I t  fu r th e r  concluded th a t  Congress m ay only 
reg u la te  ind iv iduals once they  “actua lly  e n te r  the  
s tream  of com m erce and  consum e h e a lth  care.” Id. 
a t 118a.

As th is  C ourt h a s  recognized, s tru c tu ra l lim ita ­
tions on C ongress’s au th o rity  can serve th e  im por­
ta n t  function of p ro tecting  ind iv iduals ag a in s t abuse 
of governm ent power. See Bond u. United States, 
131 S. Ct. 2355, 2364 (2011) (“[F ed e ra lism  pro tects 
th e  liberty  of th e  indiv idual from  a rb itra ry  pow er.”). 
The E leventh  C ircuit, however, m isconceived the  
liberty  in te re s ts  a t s take  in  th is  case. W hile it  is 
tru e  th a t  those who do not pu rchase  in su rance  are  
subject to a  ta x  penalty  beginning  in  2014, Pet. Br. 
11, th is  C ourt long ago rep u d ia ted  th e  notion th a t  
p riva te  economic decisions are  beyond governm ent 
regu la tions designed to serve the la rg e r good.

A t bottom , th e  challenge to th e  m inim um  cover­
age provision echoes a rg u m en ts  m ade during  the  
Lochner e ra  about law s th a t  pu rp o rted  to in te rfe re  
w ith  th e  rig h t to contract. See Lochner v. New York, 
198 U.S. 45 (1905) (strik ing  down s ta te  labor law  es­
tab lish in g  m axim um  num ber of hours for bakers). 
The C ourt h as  long since abandoned such a notion. 
In  West Coast Hotel Co. u. Parrish, for exam ple, the  
C ourt rejected  a  challenge to a s ta te  m inim um  wage 
law  on su b stan tiv e  due process grounds. 300 U.S. 
379, 392-93 (1937) (collecting cases). The C ourt



14

observed th e  now fam ilia r princip le th a t  th e  gov­
e rn m en t m ay reasonab ly  reg u la te  p riv a te  economic 
decisions to advance th e  public in te re s t. Id. a t 392; 
see also Washington v. Glucksberg, 521 U.S. 702, 761 
(1997) (Souter, J ., concurring) (describing rep u d ia ted  
economic due process cases); NLRB v. Jones & 
Laughlin Steel Corp., 301 U.S. 1, 46 (1937) (uphold­
ing federal law, enacted  u n d e r C ongress’s Commerce 
power, th a t  p roh ib ited  d ischarg ing  em ployees based  
on un ion  m em bership).

1. The provision imposes minimal burdens on 
liberty.

A lthough th e  m in im um  coverage provision is 
com m only described as a “m an d a te ,” it  is w orth  c la ri­
fying f irs t th a t  th e  provision does not requ ire  in d i­
v iduals to pu rch ase  any  p a rtic u la r  in su ran ce  product 
or service. See Pet. App. 25a-26a (citing 26 U.S.C. 
§ 5000A(f)(l)). In s tead , covered persons m ay elect to 
pay  a  financial p en a lty  th a t  is enforced by an  “offset 
[of] any  ta x  re fund  owed th e  u n in su red  tax p ay er.” 
Id. a t  45a. Thus, th e  p rac tica l com pulsory effect on 
an  in d iv idua l’s personal choice w h e th er to buy 
in su ran ce  is m inim al. For th ese  reasons, th e  ab ility  
to self-insure  is no t analogous to any  liberty  in te r ­
ests  th a t  th e  C ourt h a s  d e term ined  a re  co n stitu tio n ­
ally cognizable.

A few exam ples illu s tra te  th is  point. Cf. Glucks­
berg, 521 U.S. a t  722 (observing u tility  of “concrete 
exam ples” for d e term in ing  ou tlines of p ro tected  
liberty  in te rests). The provision does not infringe on 
bodily in teg rity ; as a lread y  m entioned, it  does no t 
requ ire  ind iv iduals to undergo  any  form  of tre a tm e n t 
or to use  any  form  of h e a lth  care. See Cruzan v. Dir.,



15

Mo. Dep’t of Health, 497 U.S. 261, 269-79 (1990) (d is­
cussing  r ig h t of com petent ind iv idual to refuse u n ­
w an ted  m edical trea tm en t); see also Rochin v. Cali­
fornia, 342 U.S. 165 (1952).9 N or does th e  provision 
in tru d e  on “personal decisions re la tin g  to m arriage, 
procreation, contraception, fam ily re la tionsh ips, 
child  rearing , and  education ,” Lawrence, 539 U.S. a t 
574; involve th e  reg u la tion  of in tim ate , p riv a te  re la ­
tionsh ips inside th e  home, id. a t 567; affect m arita l 
privacy, Griswold v. Connecticut, 381 U.S. 479 
(1965); or im plicate  th e  r ig h t to decide w h e th er to 
carry  a  p regnancy  to term , Planned Parenthood of 
Se. Pa. v. Casey, 505 U.S. 833 (1992).

F inally , th e  provision com fortably falls w ith in  the  
am bit of o th e r k inds of regu la tions im posed by 
S ta tes  th a t  requ ire  persons, u n d er pen alty  of law, to 
purchase  insu rance . Therefore, th e  provision does 
not im plicate  th e  k ind  of liberty  in te re s t th a t  is “ob­
jectively, ‘deeply rooted in  th is  N ation ’s h is to ry  and  
tra d itio n .’” Glucksherg, 521 U.S. a t 720-21 (quoting 
Moore v. City of East Cleveland, 431 U.S. 494, 503 
(1977) (p lu rality  opinion)). M ost S ta tes , for exam ple, 
requ ire  ind iv iduals to purchase  car in su rance  as a 
condition of vehicle reg is tra tio n  (presum ably  even if 
th ey  never drive th e ir  car). See, e.g. , Delaware v.

9 Notably, in  Jacobson v. M assachusetts, 197 U.S. 11 (1905), 
the  Court repud iated  the assertion th a t a compulsory smallpox 
vaccination was “hostile to the inheren t righ t of every freem an 
to care for his own body and hea lth  in  such way as to him  
seems best.” Id. a t 26. Observing “the fundam ental principle 
th a t persons and property are subjected to all kinds of re ­
stra in ts  and  burdens in  order to secure the general comfort, 
health , and prosperity  of the state ,” id. (in ternal quotation 
m arks omitted), the  Court upheld the  law on the grounds th a t 
it promoted public hea lth  and safety, id. a t  31.



16

Prouse, 440 U.S. 648, 658-59 (1979); Garcia v. Van­
guard Car Rental USA, Inc., 540 F .3d 1242, 1247-48 
(11th  Cir. 2008). S im ilarly , S ta te s  m ay condition a 
professional license on ob ta in ing  m alpractice  in s u r­
ance. See, e.g., Ophthalmic Mut. Ins. Co. v. Musser, 
143 F .3d 1062 (7 th  Cir. 1998). T hus, as Ju d g e  S u t­
ton  observed in  h is  opinion in  Thomas More Law  
Center v. Obama, th e  provision does little  m ore th a n  
is req u ired  by S ta te s  in  analogous contexts. See 651 
F .3d 529, 565 (6 th  Cir. 2011) (S utton , J ., concurring) 
(describing S ta te  law s th a t  req u ire  ind iv iduals to 
buy  m edical in su ran ce  an d  car insurance).

2. Under the Court’s Commerce Clause 
jurisprudence, individuals must sometimes 
yield economic liberty to advance the collec­
tive good.

The C ourt’s Com m erce C lause cases acknow ledge 
th a t  governm ent’s economic reg u la tio n  m ay lim it in ­
d iv idual liberty  to serve th e  com m on good. Wickard 
v. Filburn, 317 U.S. I l l  (1942), is a  c lear exam ple. 
C o n tra ry  to  th e  conclusion of th e  E leven th  C ircuit, 
Wickard supports  the  a u th o rity  of C ongress to enact 
th e  m in im um  coverage provision u n d e r its  Com­
m erce C lause power. In  lig h t of th e  court of 
app ea ls’s extensive tre a tm e n t of Wickard, Pet. App. 
65a-68a, l l la -1 1 5 a ,  and  its  close re la tio n sh ip  to th e  
lib e rty  in te re s t suggested  in  th is  case, it deserves 
close scru tiny .

In  Wickard, th is  C ourt considered th e  co n stitu ­
tio n a lity  of a p en a lty  im posed on a  sm all com m ercial 
fa rm er who produced w h eat in  excess of h is  a llo tted  
acreage u n d e r th e  federal A gricu ltu ra l A d justm en t 
Act. The purpose of th e  law  w as to reg u la te  th e  su p ­



17

ply an d  dem and  for w heat in  order to p rev en t price 
fluc tuations and  to stabilize th e  in te rs ta te  m arket. 
317 U.S. a t 115. Wickard is significant because the  
fa rm er (F ilburn) grew  m ore th a n  h is quo ta  not for 
th e  purpose of selling it on th e  in te rs ta te  m arke t, 
b u t for h is  own p riv a te  consum ption a t  home. Id. a t 
114. This fact did not m a tte r  u n d e r th e  law , how ­
ever. Any w heat grow n in  excess of th e  p rescribed  
a llo tm en t w as subject to pen alty  an d  did “not depend 
upon w h e th er any p a r t of th e  w h eat e ith e r w ith in  or 
w ithou t th e  quota [was] sold or in tended  to be sold.” 
Id. a t 119.

The court of appeals d istingu ished  th e  liberty  in ­
te re s ts  im plicated  by Congress’s w heat regu la tion  in 
Wickard on two grounds. F irst, F ilb u rn  w as a  com­
m ercial fa rm er and, therefore, h ad  a lready  chosen to 
place h im se lf “in  com m erce” as opposed to ind iv idu ­
als here  who are  — u n d er R espondents’ view — “com­
pel [led]” to e n te r  com m erce to purchase  ind iv idual 
h e a lth  insu rance . Pet. App. 98a. Second, th e  court 
observed th a t  th e  A gricu ltu ra l A d justm en t Act “did 
no t requ ire  h im  to purchase  m ore w heat.” Id. a t 
111a. R ather, F ilb u rn  re ta in ed  a num ber of o ther 
options: “He could have decided to m ake do w ith  the  
am ount of w heat he w as allowed to grow. He could 
have red irec ted  h is efforts to ag ricu ltu ra l endeavors 
th a t  req u ired  less w heat. He could have even ceased 
p a r t of h is  farm ing  operations.” Id. a t  l l la -1 1 2 a .  In  
o ther w ords, F ilb u rn  w as s till free to exercise some 
choice, an  option th a t  th e  court of appeals concluded 
is lost as a  re su lt of th e  m inim um  coverage provi­
sion. Id. a t 112a.

The E leven th  C ircuit’s analysis oversta tes the  
significance of F ilb u rn ’s farm ing  operation  an d  res ts



18

on a false ch arac te riza tio n  of th e  n a tu re  of th e  choice 
th a t  w as a t  issue  in  Wickard. A lthough F ilburn  
techn ically  w as a  com m ercial farm er, th is  C ourt did 
not tre a t  th e  activ ity  in  question  — “cu ltiva tion  of 
w h ea t for hom e consum ption” — “as p a r t of h is  com ­
m ercial farm ing  operation .” Gonzales v. Raich, 545 
U.S. 1, 20 (2005). M ore im p o rtan t, th e re  is no ques­
tion  th a t  F ilb u rn  could no t choose to grow w h eat -  
even for h is  own p riv a te  consum ption  -  beyond th e  
am o u n t a llo tted  to h im  u n d e r th e  A gricu ltu ra l A d­
ju s tm e n t Act. If  he  w an ted  to sell all of h is  p re ­
scribed share , he would be req u ired  to purchase any 
add itiona l w h ea t for h is  personal use. As w ith  in d i­
v iduals who p refer to self-insure, F ilb u rn  p referred  
to  grow m ore w h eat precisely  so th a t  he could avoid 
hav ing  to buy it. Yet, as th e  C ourt expressly  ac­
know ledged, th e  law  “forc[ed] some fa rm ers  in to  th e  
m a rk e t to buy  w h a t th ey  could provide for th e m ­
selves.” Wickard, 317 U.S. a t  129. F ilburn , in  o ther 
words, w as “com pelled” to e n te r  th e  s tream  of com­
m erce to pu rch ase  a  p roduct th a t  he  would have o th ­
erw ise chosen to cu ltiva te  h im self. See Thomas More 
Law Ctr., 651 F.3d a t  560-61 (Sutton, J ., concurring).

To m eet its  objective of s tab ilizing  th e  w heat 
m ark e t, C ongress needed to reg u la te  F ilburn , ju s t as 
it  now needs to reg u la te  th e  w illfully u n in su red  to 
stab ilize  th e  m ark e t for h e a lth  in su ran ce  an d  h e a lth  
care. As th e  Wickard C ourt noted, it  is sim ply th e  
n a tu re  of reg u la tion  “th a t  it  lays a re s tra in in g  h an d  
on th e  self-in terest of th e  reg u la ted  and  th a t  ad v an ­
tag es  from  th e  reg u la tion  com m only fall to o thers .” 
317 U.S. a t  129.10 This is a common them e of the

10 The Court fu rth e r observed th a t  these legislative choices 
“are wisely left under our system  to resolution by the Congress



19

C ourt’s com m erce cases. See United States v. Darby, 
312 U.S. 100, 114-15 (1941); Jones & Laughlin Steel, 
301 U.S. a t  31-32; see also Raich, 545 U.S. 1 (con­
cluding th a t  application of federal law  th a t  c rim in a l­
ized possession an d  use of m ariju an a  for m edical 
purposes to in tra s ta te  grow ers and u sers  did not vio­
la te  Commerce Clause).

Like th e  law  challenged in  Wickard, an d  as w ith  
o th er federal program s th a t  depend on indiv idual 
pa rtic ip a tio n  to be viable, th e  m in im um  coverage 
provision requ ires  n early  all persons, subject to 
im p o rtan t exceptions,11 to m ake a financial co n tribu ­
tion. In  United States v. Lee, 455 U.S. 252 (1982), 
th e  C ourt upheld  a  sim ila r financial “m an d a te” in  
th e  context of social security  a fte r factoring in  the  
size and  im portance of th e  governm ent program . 
The C ourt rejected  an  as-applied  challenge to th e  
constitu tiona lity  of a  social security  ta x 12 u n d e r th e  
F ree Exercise C lause. A m em ber of th e  Old O rder 
A m ish challenged th e  m an d ate  on th e  grounds th a t  
bo th  contribu tions to th e  social security  system  and  
receip t of any  benefits constitu tionally  in fringed  his 
religious beliefs. Id. a t 255. Accepting th e  con ten­
tions th a t  “both  paym en t an d  receip t of social secu­
rity  benefits is forbidden by th e  A m ish fa ith ” and  
th a t  “com pulsory p artic ip a tio n  in  th e  social security

u nder its  more flexible and responsible legislative process,” 
particularly  where such flexibility is needed to adapt legislation 
to the changing practical realities of our modern, in tegrated  
economy. 317 U.S. a t 129.

11 See supra  note 8.

12 Amici do not take  any position on w hether the m inim um  
coverage provision’s financial penalty  is a “tax .”



20

system  interfere[d] w ith  th e ir  free exercise rig h ts ,” 
id. a t  257, th e  C ourt none theless  concluded th a t  th e  
governm ent’s in te re s t “in  a ssu rin g  m an d ato ry  an d  
continuous pa rtic ip a tio n  in  an d  con tribu tion  to th e  
social security  system  [was] very  h igh .” Id. a t  258- 
59 .13 W hile no t a case about th e  scope of C ongress’s 
Com m erce power, Lee ra ises  analogous concerns 
about th e  balance  betw een  ind iv idual liberty  an d  
governm ent regu la tions designed  to advance th e  
com m on good. This C ourt re s ted  its  Lee decision in  
p a r t on th e  role th a t  social secu rity  p layed in  
“se rv in g ] th e  public in te re s t by providing a  com pre­
hensive in su ran ce  system  w ith  a v a rie ty  of benefits 
availab le  to all p a rtic ip an ts , w ith  costs sh ared  by 
em ployers and  em ployees.” Id. a t  258. As w ith  th e  
provision challenged here, w hich is an  essen tia l p a r t 
of ACA’s regu la to ry  fram ew ork, C ongress d irected  
ind iv iduals to  con tribu te  financial resources on th e  
ground th a t  “m an d ato ry  p a rtic ip a tio n  is in d isp en sa ­
ble to th e  fiscal v ita lity  of th e  . . . system .” Id.

These cases dem o n stra te  th a t  th e  C ourt need  not 
privilege th e  economic choice of a  subse t of in d iv idu ­
als to  self-insure, w hile d isregard ing  th e  effect such 
decisions have on th e  ab ility  of persons who want 
in su ran ce  to choose it. The m in im um  coverage p ro ­

13 The Court reached th is  conclusion in  Lee even though it 
applied heightened scrutiny. 455 U.S. a t 257-60. The Court 
subsequently  ruled, in Em ploym ent D ivision v. Sm ith , 494 U.S. 
872 (1990), th a t heightened scrutiny does not apply to claims of 
religious exemption from a n eu tra l and  generally applicable 
law. Cf. Hosanna-Tabor Evangelical Lutheran Church & Sch.
v. EEOC, No. 10-553, 556 U .S .___(2012), slip op. a t  15 (Jan.
11, 2012) (discussing Sm ith).



21

vision’s lim ita tions on ind iv idual liberty  are  fully 
consisten t w ith  th e  C onstitu tion .

II. T he N e c e ssa r y  an d  P ro p er  C lau se  fu r th er
su p p o rts  th e  c o n s t itu t io n a lity  o f  th e  m in i­
m u m  co v er a g e  p ro v is io n .

The principle th a t  Congress m ay enac t law s “nec­
essary  and  proper” to th e  execution of its  en u m er­
a ted  pow ers h as  been firm ly estab lish ed  for n early  
200 years, McCulloch v. Maryland, 4 W heat. 316 
(1819), and  repeated ly  reaffirm ed by th is  C ourt as 
an  essen tia l ing red ien t of our constitu tiona l system , 
including  m ost recen tly  in  United States v. Com­
stock, 130 S. Ct. 1949 (2010). The m inim um  cover­
age provision easily  satisfies th e  constitu tiona l s ta n ­
d ards set fo rth  in  th is  C ourt’s cases in te rp re tin g  the  
N ecessary  and  P roper C lause an d  should be upheld  
for th a t  reason, as well.

The m inim um  coverage provision does not exist 
in  legislative isolation. I t  is p a r t  of a com prehensive 
leg islative schem e an d  its  va lid ity  u n d e r the  
N ecessary  an d  P roper C lause m u st be evalua ted  in  
lig h t of th a t  schem e. In  p a rticu la r, th e  m inim um  
coverage provision is closely tied  to two o th er provi­
sions of the  h e a lth  care law: one proh ib its in su rance  
com panies from  denying h ea lth  care coverage to in ­
dividuals based  on pre-ex isting  conditions or m edical 
h istory , 42 U.S.C. §§ 300gg-l(a), 300gg-3(a), th e  
o th er proh ib its in su rance  com panies from  charg ing  
such indiv iduals a h igher prem ium , id. § 300gg. To­
gether, th ese  provisions a re  designed to address a 
free rid e r problem  th a t  cu rren tly  d is to rts  th e  n a ­
tiona l h e a lth  care m arket, increasing  the  cost of 
in su rance  and  decreasing th e  num bers insured .



22

The a u th o rity  of C ongress to enac t th e  la t te r  two 
provisions u n d e r th e  Com m erce C lause h a s  no t been 
seriously  questioned , see Seven-Sky v. Holder, 661 
F .3d 1, 14 (D.C. Cir. 2011), an d  for good reason . In ­
su rance  com panies a re  in d isp u tab ly  engaged in  eco­
nom ic activ ity  an d  th a t  economic activ ity  unden iab ly  
h as  a su b s ta n tia l effect on in te rs ta te  com m erce. As 
th e  leg islative  findings th a t  w ere incorpora ted  in  
ACA specifically note:

The cost of providing uncom pensated  care  to 
th e  u n in su red  w as $43,000,000,000 in  2008.
To pay  for th is  cost, h e a lth  care providers 
pass on th e  cost to  p riv a te  in su re rs , w hich 
pass on th e  cost to fam ilies. This cost- 
sh ifting  increases fam ily p rem ium s by on av ­
erage over $1,000 a year.

42 U.S.C. § 18091(a)(2)(F).

Congress fu r th e r  found th a t  th e  m in im um  cover­
age provision w as “e ssen tia l to c rea tin g  effective 
h e a lth  in su ran ce  m ark e ts  in  w hich im proved h e a lth  
in su ran ce  products th a t  a re  g u a ran teed  issue  an d  do 
not exclude coverage of p re-ex isting  conditions can 
be sold.” Id. § 18091(a)(2)(I). The provision 
“b roaden  [s] th e  h e a lth  in su ran ce  risk  pool to  include 
h ea lth y  ind iv iduals” who m ight o therw ise  choose to 
rem a in  u n in su red  or defer in su ran ce  coverage. Id. 
This expanded pool, in  tu rn , enables in su ran ce  com­
p an ies to provide in su ran ce  coverage to everyone a t 
low er p rem ium s. Id. § 18091(a)(2)(F).

“[W ]here Congress h as  th e  a u th o rity  to en ac t a 
regu la tion  of in te rs ta te  commerce, ‘it  possesses every 
pow er needed to m ake th e  reg u la tion  effective.’” 
Raich, 545 U.S. a t  36 (Scalia, J ., d issenting) (quoting



23

United States v. Wrightwood Dairy Co., 315 U.S. 
110, 118-19 (1942)). T h a t is precisely w h a t th e  
m in im um  coverage provision does in  th is  case. 
M oreover, C ongress is generally  g ran ted  b road  d is­
cretion  in  determ in ing  w h a t leg islation  is necessary  
an d  proper to effectuate its  en um erated  powers. See 
Sabri v. United States, 541 U.S. 600, 605 (2004).

To be sure, th e  N ecessary  and  P roper C lause is 
not an  u n lim ited  license for Congress to enact any  
leg islation  it chooses. In  Comstock, Ju s tice  K ennedy 
an d  th e  m ajority  debated  about w h e th er th e  link  to 
an  en u m era ted  pow er m u st be one th a t  is ra tiona lly  
conceivable or em pirically  rooted. B ut th a t  debate  
h as  no relevance here. Even accepting Ju stice  
K ennedy’s view th a t  “[t]he ra tio n a l basis  re fe rred  to 
in  th e  Com m erce C lause context is a d em onstra ted  
link  in  fact,” 130 S. Ct. a t 1967 (K ennedy J., concur­
ring), th a t  “lin k  in  fact” is am ply “d em o n stra ted ” by 
th e  leg islative  findings supporting  en ac tm en t of the  
Affordable C are Act.

N or does it m a tte r  for purposes of th e  N ecessary  
an d  P roper C lause w h e th er th e  m inim um  coverage 
provision is independen tly  supported  by th e  Com­
m erce C lause, a lthough  am ici believe th a t  it  is for 
th e  reasons s ta ted  above. See supra P a r t I. I t  is 
enough, as th is  C ourt h as  noted, th a t  th e  provision is 
“an  essen tia l p a r t of a  la rg e r regu la tion  of economic 
activity, in  w hich th e  regu la to ry  schem e could be 
u n d ercu t un less th e  . . . activ ity  [at issue] w ere reg u ­
la ted .” United States v. Lopez, 514 U.S. 549, 561 
(1995).

F inally , in  exercising its  pow ers u n d e r the  N eces­
sary  and  P roper C lause, Congress cannot abridge



24

fu n d am en ta l r ig h ts  any  m ore th a n  it  m ay in  th e  ex­
ercise of its  en u m era ted  pow ers. See Comstock, 130 
S. Ct. a t  1957. As noted, supra P a r t  I.C, however, 
th e  economic lib e rty  in te re s ts  suggested  h ere  in  op­
position  to th e  m in im um  coverage provision do not 
rise  to th a t  level.

CO N C LU SIO N

For th e  foregoing reasons, th e  C ourt should  re ­
verse th e  ju d g m en t of th e  E leven th  C ircuit s trik in g  
down th e  m in im um  coverage provision.

R espectfully  subm itted ,

J ohn Payton 
D irector-C ounsel 

Debo P. Adegbile 
Elise C. Boddie 

Counsel of Record 
ReNika C. Moore 
Ria A. Tabacco 
NAACP Legal Defense & 

Educational Fund, Inc. 
99 H udson St., 16th  Floor 
New York, NY 10013 
(212) 965-2200 
eboddie@ naacpldf. org

J oshua Civin 
NAACP Legal Defense & 

Educational Fund, Inc. 
1444 I St., NW, 10th  Floor 
W ashington, DC 20005



25

J a n u a r y  13, 2012

St e v e n  R. Sh a piro  
Am e r ic a n  C iv il  L ib e r t ie s  

U n io n  F o u n d a tio n  
125 B ro ad  S tre e t 
N ew  Y ork, NY 10004

L isa  M. B o r n st e in  
L e a d e r sh ip  Co n f e r e n c e  

o n  C iv il  and  H u m an  
R ig h ts

1629 K  S tre e t, N W  
W ash in g to n , DC 20006

Counsel for Amici Curiae



/