Three months later, though, the court upholds the individual insurance mandate viewed as the linchpin of the ACA and does so with legal reasoning so unexpected that CNN and Fox News incorrectly report that the mandate was struck down. Chief Justice John Roberts joins the court's liberal wing to preserve the mandate based on little-noticed legal reasoning floated by the Obama administration: that even if the mandate is an unconstitutional extension of Congress' power under the commerce clause, it's a legitimate exercise of taxing power.
Less noticed in the moment but hugely important in the months that follow, a majority of the justices conclude HHS cannot withhold all Medicaid dollars from states that decline to expand eligibility to at least 133% of the federal poverty level. The Medicaid expansion had been expected to reach 17 million Americans and account for a substantial portion of the reduction in the number of uninsured achieved by the law.
The Congressional Budget Office later estimates that the outcome means 6 million fewer people will get new Medicaid coverage, although the CBO presumes 3 million will instead get subsidized coverage in the health insurance exchanges established under the law. The reality, however, remains murky for the rest of the year as governors see new leverage to pry concessions from the CMS on their Medicaid obligations in exchange for helping the feds meet the ACA's coverage goals.