As the U.S. Supreme Court ponders the constitutionality of the Affordable Care Act after three days of oral arguments, President Barack Obama warned April 2 that "unelected" justices should not overturn the will of Congress.
Declaring the health law "constitutional," the president said, "We are confident that this will be upheld because it should be upheld."
Turning the tables on Republican lawmakers and right-wing commentators who often accuse liberal justices of engaging in "judicial activism or lack of judicial restraint," the president argued, "That an unelected group of people would somehow overturn a duly constituted and passed law. Well, here's a good example."
Obama said he hopes that, in the political and legal debate over the law, the "human" dimension is not forgotten.
"We're all on pins and needles on the Supreme Court stuff," Robert Ross, president and CEO of the California Endowment, a health care foundation, told the Sacramento Bee. "We still have 7 million uninsured in the state, and we still have out-of-control health care costs."
The justices are expected to reach a final decision by the end of June, including whether Congress can require people to buy health insurance and states to expand coverage under Medicare, known as Medi-Cal in California.
Through Medi-Cal, the state now serves nearly 8 million low-income residents, including children and their parents, disabled individuals and the elderly. Under Healthy Families, a separate program, California provides coverage to 878,000 children up to age 19 whose family income exceeds Medi-Cal qualifications.
Through the federal health care law, the federal government would cover most costs for new enrollees, including single adults and parents who do not now qualify for Medi-Cal.
From 2014 to 2019, California could receive $45 billion to $55 billion from the federal government, while the state would contribute an additional $3 billion to $6 billion, according to the Kaiser Commission on Medicaid and the Uninsured.
Highlighting the stakes in the Supreme Court decision over the law, Health Access California Executive Director Anthony Wright said, "It's an infusion of literally billions of dollars into our health care system and our economy that is pending here."
Were the court to rule against the law, Wright said the state could proceed with some portions of the reform, like the insurance exchange, but "the key thing is money."
Encouraged by the White House, California two years ago became the first state nationally to enact legislation to create a public health insurance marketplace to implement the Affordable Care Act.
Starting in 2014, the exchange is expected to serve more than 2 million state residents, many of whom are currently uninsured because they cannot afford coverage or do not qualify for public health care.
Wright said the insurance exchange would "provide an easy, consumer-friendly marketplace" but without the federal dollars promised by the law "it won't be the same thing."
The California Endowment's Ross, a health insurance exchange board member, said federal funding is "the wild card in all this."
Meanwhile, California Health and Human Services Secretary Diana Dooley said the state should consider enacting its own universal health care legislation, including requiring all Californians to buy insurance, if the court rules the federal law unconstitutional.
"If we ask the insurance plans to take everybody and insure everybody with no screens or pre-existing conditions," Dooley told the Sacramento Bee, "then we have to have everybody buying some level of health insurance to meet their responsibility to the system."