As arguments and questions swirled around him, U.S. Supreme Court Chief Justice John Roberts sat quietly at the center of the bench.
Only toward the end of oral arguments in the blockbuster King v. Burwell case in March did he ask a telling question. That query hinted at the majority opinion he wrote in June, upholding by a 6-3 vote the Obama administration's interpretation of a key provision of the Affordable Care Act. The ruling made reinterpreting that provision virtually impossible if a Republican president succeeds Barack Obama.
Roberts' influence on healthcare this year and in years past is hard to overstate. In the King case, he was one of two conservatives who voted to allow the ACA's premium subsidies in all states, which in the view of many experts saved the healthcare reform law. His written opinion was taken by many observers to mean the Roberts court is finished considering the fundamental legality of the ACA.
In 2012, Roberts provided the swing vote and wrote the majority opinion in National Federation of Independent Business v. Sebelius upholding the constitutionality of the ACA's requirement that all Americans obtain health insurance, another foundation of the law. In that case, however, he also voted to make the ACA's Medicaid expansion optional for states, which has left millions of Americans uninsured.
“Without the vote of Chief Justice Roberts, the ACA very well may not exist,” said Joshua Blackman, an associate professor at South Texas College of Law who wrote a book about the NFIB case. And a different decision in King v. Burwell would have thrown a serious wrench into the ACA, he added. “In both cases, the chief justice made clear it's up to Congress to change the ACA.”
Roberts placed No. 1 on Modern Healthcare's ranking of the 100 Most Influential People in Healthcare for 2015. He also topped the list in 2012.