In a 5-to-4 decision, the U.S. Supreme Court upheld the Obama administration’s Affordable Care Act (ACA) in 2012, including the controversial “individual mandate” requiring people to buy insurance or pay a penalty. Chief Justice John Roberts, who wrote the opinion for the majority, sided with the more liberal associate justices – Stephen Breyer, Ruth Bader Ginsburg, Sonia Sotomayor and Elena Kagan – providing the swing vote declaring most of the law constitutional.

Passage of the ACA in 2010 divided both Congress and the country. Portions of the law affect virtually everyone – from doctors and hospitals to insurance companies, from small businesses to large corporations, and from anyone who is now a patient to anyone who may one day become a patient.

Supporters of the ruling are hailing it as a win for all Americans, but particularly for anyone with a chronic medical condition. "The ACA has already begun making a difference in the lives of people with arthritis," says Amy Melnick, chief public policy officer for the Arthritis Foundation. "Young adults with pre-exiting conditions gained protection from health insurance discrimination with the age-extension allowed for dependent coverage under a parent's plan. Seniors paid less out of pocket for prescriptions, narrowing the Medicare Part D 'donut hole' gap in coverage. And people with rheumatoid arthritis, osteoarthritis or any other costly condition who had been shut out of the private market were able to get coverage via the Pre-existing Condition Insurance Plan, or PCIP. 

The law eliminates many of the risks faced by the 50 million Americans with arthritis and the countless others with chronic conditions. In addition to guaranteed insurance coverage, other provisions will be phased in over the next few years, including no lifetime caps on insurance benefits and an end to unlimited out-of-pocket costs.

“This is an important victory for people with chronic diseases. It means that starting in 2014, they are guaranteed to be able to obtain health insurance. Had the decision gone the other way, insurers could have continued to shut them out,” says Robert I. Field, PhD, a law professor at Earle Mack School of Law and a professor of health management and policy, at Drexel University School of Public Health, in Philadelphia.

“The ruling also means that all of the consumer protections in the law will also survive,” says Field.

Not everyone is happy with the decision. Opponents view the law as federal intrusion into what ought to be a private realm; they oppose the individual mandate, which requires that individuals buy insurance or face a financial penalty. They also fear the ACA will increase regulatory burdens and that the law will limit their access to care. Others question whether the act will lower insurance premiums and cap spiraling health care costs, as promised. Still others are concerned that employers who are unable to provide coverage will be forced to cut jobs instead. Congressional Republicans have vowed to repeal the law.

The Controversial Mandate

The most embattled part of the law has been the individual mandate, which requires that anyone who can afford to buy insurance must do so or pay a penalty based on individual income. People who cannot afford even the least expensive insurance plan would be exempt from the penalty. Opponents believe that purchasing health insurance should be an individual choice, not a governmental requirement. The Supreme Court upheld the mandate, but in a surprise move it said the individual mandate wasn’t constitutional under the Commerce Clause of the Constitution – which was the main argument put forward by the Obama administration. Instead the Supreme Court ruled that the penalty is a form of tax, which Congress does have the power to impose.