First, for most Americans the amount due will be far less than the price of insurance, and, by statute, it can never be more. It may often be a reasonable financial decision to make the payment rather than purchase insurance . . .
Indeed, it is estimated that four million people each year will choose to pay the IRS rather than buy insurance. See Congressional Budget Office, supra, at 71. We would expect Congress to be troubled by that prospect if such conduct were unlawful. That Congress apparently regards such extensive failure to comply with the mandate as tolerable suggests that Congress did not think it was creating four million outlaws. It suggests instead that the shared responsibility payment merely imposes a tax citizens may lawfully choose to pay in lieu of buying health insurance.
So the tax is acceptable, in part, because it is trivial.
Imagine, for the sake of argument, you accept the basic position that it is the state’s responsibility to provide universal health care coverage.
The problem: to the extent that the tax is trivial, it will be ineffective. That is, it would be quite rational—as recognized by Roberts—for an individual to pay a small tax and avoid large premiums. It would be rational, once again, to do this up to the moment when one would require serious medical attention, at which point the ACA limits the amount that can be charged for entry into the system and prohibits discrimination based on pre-existing conditions.
The ACA—by design or by accident—seemed to neglect this issue.
Another point: while one might have little concern over those who make a rational decision not to purchase insurance, one might have a far different response to those who want insurance but simply do not have the wherewithal to purchase it. These were the folks who might have been covered by the expansion of Medicaid. Now that states cannot be punished for refusing to extend Medicaid as required under the ACA, I am assuming many (most) states will not provide additional coverage.
Yes, the Court upheld the ACA. But was it really more than a short-term victory for those who believe that the state has an obligation to provide universal health care coverage?