WASHINGTON – In a voluminous, complex, and divergent set of opinions, the U.S. Supreme Court, in a 5-4 ruling, upheld the constitutionality of most provisions of the Affordable Care Act on June 28.

The court’s decision that the law’s expansion of Medicaid is not lawful – but that any state that wishes to take federal matching funds to bring on more enrollees can do so – may result in reduced access to health coverage and more uninsured patients seeking care in 2014.

Protestors both for and against the Affordable Care Act flocked to the Supreme Court steps before the decision on June 28.

The majority, in a 59-page opinion, said that "the Court does not express any opinion on the wisdom of the Affordable Care Act. Under the Constitution, that judgment is reserved to the people."

In their opinion, the majority found that the ACA’s individual mandate was a violation of the Constitution’s Commerce Clause. Chief Justice John Roberts, who wrote the opinion, said that the mandate "does not regulate existing commercial activity."

According to Justice Roberts, "it instead compels individuals to become active in commerce by purchasing a product, on the ground that their failure to do so affects interstate commerce."

The opinion jibed with the argument made by plaintiffs that the government should not be allowed to compel Americans into commerce.

The majority, however, also found that requiring Americans to pay a penalty if they did not buy health insurance was constitutional. The government did not call the penalty a "tax," but the court found that it is indeed a tax, and thus, within Congress’ powers.

The majority also agreed with the plaintiffs that the federal requirement that states either accept the money offered to expand Medicaid or forego all Medicaid funds was unduly coercive. Justice Roberts characterized the requirement as "a gun to the head."

He said that the ACA transforms Medicaid into an entirely new program and thus violates Congress’ spending power under the Constitution and also violates states’ sovereignty. However, "nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of health care."

Essentially, the majority opinion says that states could accept the funds to expand their Medicaid programs but the federal government could not withdraw existing Medicaid funds from those states that choose not to take the money.

Multiple dissenting opinions were issued. Justices Antonin Scalia, Anthony Kennedy, Clarence Thomas, and Samuel Alito offered a 66-page opinion that the entire ACA is unconstitutional. In an impassioned reading from the bench, Justice Kennedy accused the majority Justices of not just ruling on the law, but of essentially rewriting it for Congress.

The majority ruling "creates a debilitated, inoperable version of health care regulation that Congress did not enact and the public does not expect," said Justice Kennedy, reading from the dissent. "It makes enactment of sensible health care regulation more difficult, since Congress cannot start afresh but must take as its point of departure a jumble of now senseless provisions, provisions that certain interests favored under the Court’s new design will struggle to retain," he said.

The dissent also took issue with the ruling on Medicaid expansion, saying that states declining federal funds would end up subsidizing the expansion in other states through their residents’ tax dollars.

Justices Ruth Bader Ginsburg, Sonia Sotomayor, Stephen Breyer, and Elena Kagan also offered a dissent. Writing for that group, Justice Ginsburg said that the individual mandate was valid under the Commerce Clause. In the dissent, only Justice Ginsburg said that the Medicaid expansion was a proper use of Congress’ authority.

Outside the court and across Washington, supporters and opponents of the ACA gave their views on the decision.

"This is a hallelujah moment for American families," said Families USA Executive Director Ron Pollack, who spoke on the court steps.

Rep. Michael Burgess (R-Tex.), a physician, issued a statement condemning the Affordable Care Act.

"This decision by the Supreme Court is paramount and signals to the House of Representatives that it is our responsibility to repeal this over burdensome law which increases taxes on middle class families, and replace it with common-sense policies that encourage economic growth and protect Americans’ access to care. The House has voted to repeal the legislation and will do so again next month," said Rep. Burgess.

Dr. Jeremy A. Lazarus, president of the American Medical Association, praised the court’s decision. "This decision protects important improvements, such as ending coverage denials due to pre-existing conditions and lifetime caps on insurance, and allowing the 2.5 million young adults up to age 26 who gained coverage under the law to stay on their parents’ health insurance policies," he said in a statement. "The decision upholds funding for important research on the effectiveness of drugs and treatments and protects expanded coverage for prevention and wellness care, which has already benefited about 54 million Americans."

Rep. Tom Price (R-Ga.), who has introduced H.R. 3000, a bill to replace the ACA, said that the court "has set a dangerous precedent.

"We have no choice but to exercise every possible legislative option to repeal this disastrous law, and the American people should know that House Republicans will continue to advocate on their behalf to restore personal control over health care decisions," he said in a statement.

Justices Uphold ACA, Strike Medicaid Expansion