WASHINGTON — The Supreme Court, seemingly split over ideology, wrapped up public arguments Wednesday on President Barack Obama's historic health care law, which is designed to extend health insurance to most of the 50 million Americans now without it.
The first and biggest issue the justices must decide is whether the centerpiece of the law, the requirement that nearly all Americans carry insurance or pay a penalty, is constitutional. Wednesday's argument time was unusual in that it assumed a negative answer to that central question. What should happen to other provisions, the justices and lawyers debated, if the court strikes down the requirement?
Both liberal and conservative justices appeared on Wednesday to accept the administration's argument that at least two important insurance changes are so closely tied to the must-have-coverage requirement that they could not survive without it: provisions requiring insurers to cover people regardless of their existing medical problems and limiting how much those companies can charge in premiums based on a person's age or health.
Less clear was whether the court would conclude the entire law, with its hundreds of unrelated provisions, would have to be cast aside.
The justices also spent part of the day considering a challenge by 26 states to the expansion of the federal-state Medicaid program for low-income Americans — an important feature which alone was expected to extend coverage to 15 million people and which no lower court has rejected.
Solicitor General Donald Verrilli Jr. took a few seconds at the end of the Medicaid argument to make a final plea for the court to uphold the entire law, which he said would "secure the blessings of liberty" for millions of Americans by providing them with affordable health care.
Verrilli told the court that Congress had made a policy decision to fight the high cost of medical care through the new law. "I would urge the court to respect that judgment," he said.
Paul Clement, the lawyer for the states challenging the law, retorted that it would be a strange definition of liberty to make people who may not want it buy health care insurance. And he called Congress' threat to cut all Medicaid funding from states that refuse to expand the program "a direct threat to our federalism."
In their questions Wednesday, liberal justices Sonia Sotomayor, Elena Kagan, Ruth Bader Ginsburg and Stephen Breyer took issue with Clement, who was asking that the Patient Protection and Affordable Care Act be tossed out in its entirety.
"What's wrong with leaving this in the hands of those who should be fixing this?" asked Sotomayor, referring to Congress.
Chief Justice John Roberts also spoke about parts of the law that "have nothing to do with any of the things we are" talking about.
For example, Ginsburg observed that the act deals with issues such as black lung disease.
"Why make Congress redo those?" she asked. "There are many things" that have "nothing to do with affordable health care."
But Clement said the court would be leaving "a hollow shell" if it decided to excise the several key provisions. "The rest of the law cannot stand," he contended.
Roberts and Justice Anthony Kennedy also asked hard questions of Deputy Solicitor General Edwin Kneedler that indicated they are at least considering Clement's arguments. Kneedler said that the only other provisions the court should kill in the event the mandate is stricken are the two that bar refusing coverage to sick people and limiting the charges to old or sick people.
Justice Antonin Scalia suggested many members of Congress might not have voted for the bill without the central provisions, and he said the court should not go through each and every page to sort out what stays and what goes.
In the afternoon arguments, the liberal justices made clear they would vote to uphold the Medicaid expansion, for which the federal government would pay almost all the costs.
Justices Sotomayor, Kagan, Ginsburg and Breyer voiced strong disagreement with the states' contention that the expansion of the joint state-federal program would be unconstitutionally coercive.
"Why is a big gift from the federal government a matter of coercion?" Kagan asked.