In one of the most anticipated rulings of the century, theSupreme Court has ruled 5-4 to largely uphold the PatientProtection and Affordable Care Act of 2010.

The text of the opinion, in National Federation ofBusiness vs. Sebelius, Case Number 11-393, is availablehere.

In the 90-page opinion, the court states that Congress hasno authority under the Commerce Clause of the U.S. Constitution torequire individuals to own a minimum level of insurance, but doeshave the authority to use its taxation authority to impose acoverage mandate.

However, the decision does allow states the option to not to goalong with the expansion of the Medicaid insurance program forlow-income people.

George Patton, an appellate lawyer with Bose McKinney &Evans LLP, of Washington, D.C. and Indianapolis, said under thedecision, states can choose to expand Medicaid to 133 percent, butthey are not required to.

Congress cannot “penalize States that choose not to participatein that new program by taking away their existing Medicaidfunding,” Roberts said in the majority opinion.

Regarding the individual mandate, state attorneys general andothers have been arguing that the provision inPPACA calling for most individuals to own a minimum level ofhealth insurance starting in 2014 or else pay a penalty isunconstitutional, stating that Congress has no authority tomake individuals buy a commercial insurance product.

Chief Justice John Roberts has written in an opinion for themajority that the Commerce Clause of the Constitution givesCongress no more authority to require the purchase of healthinsurance than to require the purchase of broccoli.

According to the Obama administration, a requirement thatcitizens buy health insurance is different from a requirement thatthey buy broccoli because “[h]ealth insurance is not purchased forits own sake like a car or broccoli; it is a means offinancing health-care consumption and covering universal risks,”Roberts writes.

The connection between mandated insurance purchases and futureuse of insured health care is too remote for the goverment to usethe Commerce Clause to justify the PPACA mandate, Roberts says.

But, Roberts says, “[B]roccoli are no more purchased fortheir 'own sake' than health insurance. They are purchased tocover the need for transportation and food.”

But the Constitution does give Congress the authority to “layand collect Taxes,” Roberts says.

The Obama administration and congressional PPACA supporters haveavoided calling the penalty to be imposed on taxpayers who fail tomeet individual health insurance ownership requirements a tax, but,under one Obama administration theory, “the mandate is not a legalcommand to buy insurance,” Roberts says. “Rather, it makes goingwithout insurance just another thing the Government taxes,like buying gasoline or earning income. And if the mandate is ineffect just a tax hike on certain taxpayers who do not havehealth insurance, it may be within Congress's constitutionalpower to tax. The question is not whether that is the mostnatural interpretation of the mandate, but only whether it isa 'fairly possible' one.”

Imposition of a tax “leaves an individual with alawful choice to do or not do a certain act, so long as he iswilling to pay a tax levied on that choice,” Roberts says.“The Affordable Care Act's requirement that certain individuals paya financial penalty for not obtaining health insurance mayreasonably be characterized as a tax. Because the Constitutionpermits such a tax, it is not our role to forbid it, or topass upon its wisdom or fairness.”

Justices Clarence Thomas, Antonin Scalia, Samuel Alito andAnthony Kennedy opposed the ruling and joined to write a dissentingopinion.

INDUSTRY, ANALYSTS REACT

Industry officials and analysts caution that the ultimatedecision will be left to the voters. They also caution that even ifPresident Obama wins re-election, implementation of the healthexchanges, a key component of the law, could be delayed, perhaps ayear.

The National Association of InsuranceCommissioners weighed in with a pledge to “continue to work to giveregulators the tools they need to ensure a stable health-insurancemarketplace in the states.”

The statement adds, “Where the ACA provides states withlatitude, regulators will continue to work with insurers, consumergroups and the public to provide the best regulatory frameworkgoing forward.”

However, while signing on to the NAIC statement, NAIC presidentKevin McCarty implied that he might have difficulty getting theFlorida legislature to act to implement the exchanges and otherprovisions of the law.

The state was a hotbed of opposition to the decision, and afederal court in Pensacola was the only federal court to declarethe law unconstitutional, a decision which today's Supreme Courtdecision reversed.

McCarty says, “With the affirmation of the Affordable Care Act,I remain concerned about the potential for increased healthinsurance premiums and continued disruption to the stability of themarketplace for many Floridians.

“Nevertheless, we will work with the Florida Legislature andGov. Scott to implement the Supreme Court's decision and develop animplementation strategy that minimizes market disruption and allowsFlorida's health insurers and HMOs to continue to provide coveragein our state.”

Ken Crerar, president of the Council of Insurance Agents andBrokers, says, the “ruling appears to limit the ability of thefederal government to withhold Medicaid funding to states; it issomewhat unclear at this moment what the implications of this willbe. However, it is clear that the architecture of theAffordable Care Act is not going to be overturned by the SupremeCourt.”

Andrew C. Harris, president of the National Association ofProfessional Insurance Agents, called the decision “unfortunate,”saying the bill “has been widely criticized by the public and theinsurance industry.”

But he adds, “We urge all states to now deal with the issueof insurance exchanges in a manner that guarantees the right ofinsurance consumers to rely on the expertise of licensedprofessionals as they make important decisions about their healthinsurance coverage.”

Elizabeth Festa contributed to this report.

This story originally appeared on LifeHealthPro, a sister site ofPC360.