미국 건강보험제도(‘Obamacare’) 관련 헌법적 쟁점의 분석: 미연방대법원의 2012년 Sebelius 판결을 중심으로

The structure of healthcare system in the United States has conventionally beenidentified as the one led by the private sector and supplemented by the government,notwithstanding a series of legislative efforts particularly since the early twentiethcentury to expand healthcare coverage to most of the population if not all, throughfederal statute, which in the past had been fruitful merely in part or in particularareas. The most standard form of health insurance covering most of the populationin the U.S. has been provided by the employer based on the employmentrelationship. The government has functioned to supplement by way of providing andsubsidizing such public or government insurance programs as Medicaid, Medicare,Children’s Health Insurance Program, and the Veterans Health Administration. WhenBarack Obama pledged to implement “universal healthcare” during the presidentialelection campaign in 2008, only as much as approximately 28% of the populationwas directly covered by the government programs, and approximately 15% of thepopulation was uninsured. Upon Obama’s election as the president in 2008, theObama administration propelled federal legislation at U.S. Congress for universalhealthcare, by largely incorporating the concepts and methodologies such as healthinsurance exchanges and individual mandate with penalty for noncompliance whichhad originally been advocated by the Republicans. Despite such strategic choices, theRepublican Party strongly opposed the legislation throughout the legislative process,although a federal statute was eventually enacted in 2010 with the title of the PatientProtection and Affordable Care Act (as abbreviated as ACA). The ACA sets forth the foundation for and represents the current U.S. healthcare system, which is commonlyreferred to as “Obamacare.”The ACA intends to increase the quality and the affordability of the health insurance,to lower the uninsured rate by expanding both public and private insurancecoverage, and to reduce the costs of healthcare for the individuals and thegovernment. The ACA, most part of which came into effect in January 2014, has introduceda number of mechanisms such as individual mandate, employer mandate,health insurance exchange marketplace, minimum standard, community rating, subsidies,and Medicaid expansion. Upon enactment, the opponents began challengingthe constitutionality of the ACA particularly on the two counts of individual mandateand Medicaid expansion. The U.S. Supreme Court, in National Federation ofIndependent Business v. Sebelius decided in 2012, upheld the constitutionality of theACA. First, the U.S. Supreme Court held the ACA’s individual mandate to purchasehealth insurance with the shared responsibility payment for noncompliance to be constitutionalas a constitutional exercise of Congress’s taxing power. Second, with respectto the Medicaid expansion, the U.S. Supreme Court held that, whereasCongress exceeded its spending clause authority by coercing the states into transformativechange in their Medicaid programs with the possibility of the Medicaidfunding in the form of federal subsidy to be revoked in the entirety including thepreexisting Medicaid funding in case of failure to expand eligibility pursuant to theACA without adequate prior notice thereof for voluntary consent, this is completelyremedied by limiting the power of the Secretary of Health and Human Services orthe federal government so that only the additional funding for Medicaid expansionunder ACA may be proportionally withheld for state noncompliance. The U.S. Supreme Court’s decision in Sebelius has placed the new limits on federalregulation of commerce under the commerce clause and with respect to the conditionsthat the federal government may impose on money it gives to the states underthe spending clause under the U.S. Constitution. As such, Sebelius is a landmarkdecision in the U.S. in its constitutional law and federalism jurisprudence, withbroad implications and further ramifications for Korea in its future efforts in balancingthe roles of the government and the private sector in healthcare system, in appropriately engaging the legislative process and the party politics to enhance and fortifysocial security institutions and infrastructure, and in establishing the standard ofreview in analyzing multifaceted constitutional law issues pertaining to the healthcareand social security law, system and institutions.