U.S. Code » Title 42 » Chapter CHAPTER 157— QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS › Subchapter SUBCHAPTER V— SHARED RESPONSIBILITY FOR HEALTH CARE › Part Part A— Individual Responsibility

42 U.S.C. § 18091

Requirement to maintain minimum essential coverage; findings

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Congress makes the following findings:(1) In general

The individual responsibility requirement provided for in this section (in this section referred to as the “requirement”) is commercial and economic in nature, and substantially affects interstate commerce, as a result of the effects described in paragraph (2).

(2) Effects on the national economy and interstate commerceThe effects described in this paragraph are the following:(A) The requirement regulates activity that is commercial and economic in nature: economic and financial decisions about how and when health care is paid for, and when health insurance is purchased. In the absence of the requirement, some individuals would make an economic and financial decision to forego health insurance coverage and attempt to self-insure, which increases financial risks to households and medical providers.(B) Health insurance and health care services are a significant part of the national economy. National health spending is projected to increase from $2,500,000,000,000, or 17.6 percent of the economy, in 2009 to $4,700,000,000,000 in 2019. Private health insurance spending is projected to be $854,000,000,000 in 2009, and pays for medical supplies, drugs, and equipment that are shipped in interstate commerce. Since most health insurance is sold by national or regional health insurance companies, health insurance is sold in interstate commerce and claims payments flow through interstate commerce.(C) The requirement, together with the other provisions of this Act, will add millions of new consumers to the health insurance market, increasing the supply of, and demand for, health care services, and will increase the number and share of Americans who are insured.(D) The requirement achieves near-universal coverage by building upon and strengthening the private employer-based health insurance system, which covers 176,000,000 Americans nationwide. In Massachusetts, a similar requirement has strengthened private employer-based coverage: despite the economic downturn, the number of workers offered employer-based coverage has actually increased.(E) The economy loses up to $207,000,000,000 a year because of the poorer health and shorter lifespan of the uninsured. By significantly reducing the number of the uninsured, the requirement, together with the other provisions of this Act, will significantly reduce this economic cost.(F) The cost of providing uncompensated care to the uninsured was $43,000,000,000 in 2008. To pay for this cost, health care providers pass on the cost to private insurers, which pass on the cost to families. This cost-shifting increases family premiums by on average over $1,000 a year. By significantly reducing the number of the uninsured, the requirement, together with the other provisions of this Act, will lower health insurance premiums.(G) 62 percent of all personal bankruptcies are caused in part by medical expenses. By significantly increasing health insurance coverage, the requirement, together with the other provisions of this Act, will improve financial security for families.(H) Under the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act (42 U.S.C. 201 et seq.), and this Act, the Federal Government has a significant role in regulating health insurance. The requirement is an essential part of this larger regulation of economic activity, and the absence of the requirement would undercut Federal regulation of the health insurance market.(I) Under sections 2704 and 2705 of the Public Health Service Act [42 U.S.C. 300gg–3, 300gg–4] (as added by section 1201 of this Act), if there were no requirement, many individuals would wait to purchase health insurance until they needed care. By significantly increasing health insurance coverage, the requirement, together with the other provisions of this Act, will minimize this adverse selection and broaden the health insurance risk pool to include healthy individuals, which will lower health insurance premiums. The requirement is essential to creating effective health insurance markets in which improved health insurance products that are guaranteed issue and do not exclude coverage of pre-existing conditions can be sold.(J) Administrative costs for private health insurance, which were $90,000,000,000 in 2006, are 26 to 30 percent of premiums in the current individual and small group markets. By significantly increasing health insurance coverage and the size of purchasing pools, which will increase economies of scale, the requirement, together with the other provisions of this Act, will significantly reduce administrative costs and lower health insurance premiums. The requirement is essential to creating effective health insurance markets that do not require underwriting and eliminate its associated administrative costs.(3) Supreme Court ruling

In United States v. South-Eastern Underwriters Association (322 U.S. 533 (1944)), the Supreme Court of the United States ruled that insurance is interstate commerce subject to Federal regulation.

(Pub. L. 111–148, title I, § 1501(a), title X, § 10106(a), Mar. 23, 2010, 124 Stat. 242, 907.)Editorial NotesReferences in Text

This Act, referred to in par. (2)(C), (E) to (J), is Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 119, known as the Patient Protection and Affordable Care Act. For complete classification of this Act to the Code, see Short Title note set out under section 18001 of this title and Tables.

The Employee Retirement Income Security Act of 1974, referred to in par. (2)(H), is Pub. L. 93–406, Sept. 2, 1974, 88 Stat. 829, which is classified principally to chapter 18 (§ 1001 et seq.) of Title 29, Labor. For complete classification of this Act to the Code, see Short Title note set out under section 1001 of Title 29 and Tables.

The Public Health Service Act, referred to in par. (2)(H), is act July 1, 1944, ch. 373, 58 Stat. 682, which is classified generally to chapter 6A (§ 201 et seq.) of this title. For complete classification of this Act to the Code, see Short Title note set out under section 201 of this title and Tables.

Amendments

2010—Par. (2). Pub. L. 111–148, § 10106(a), amended par. (2) generally. Prior to amendment, par. (2) described effects of the individual responsibility requirement on the national economy and interstate commerce.

Notes of Decisions
Cited in 41 cases (2 in the last 5 years), 2010–2021 · leading case: Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566 (2012).
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Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566 (2012). · cites it 30× “42 U. S. C. §18091 (2)(F). In the Affordable Care Act, Congress addressed the problem of those who cannot obtain insurance coverage because of preexisting conditions or other health issues.”
Florida Ex Rel. Attorney Gen. v. United States Dep't of Health & Human Servs., 648 F.3d 1235 (11th Cir. 2011). · cites it 48× “Congressional Findings The congressional findings for the Act, including those relating to the individual mandate, are contained in two pages, now codified in 42 U.S.C. § 18091 (a)(1)-(3). Approximately 50 million people are uninsured.”
Thomas More Law Ctr. v. Obama, 651 F.3d 529 (6th Cir. 2011). · cites it 22× “" 42 U.S.C. § 18091 (a)(2)(H). Congress found that without the minimum coverage provision, other provisions in the Act, in particular the guaranteed issue and community rating requirements, would increase the incentives for individuals to "wait to purchase health insurance until…”
Tex. v. United States, 340 F. Supp. 3d 579 (N.D. Tex. 2018). · cites it 25× “, 42 U.S.C. §§ 18091 (2)(D), (2)(F), and (2)(I).”
State of Texas v. USA, 945 F.3d 355 (5th Cir. 2019). · cites it 10× “See 42 U.S.C. § 18091 (2)(J) (“By significantly increasing .”
Jacqueline Halbig v. Sylvia Mathews Burwell, 758 F.3d 390 (D.C. Cir. 2014). · cites it 15× “They emphasize that to achieve the goals of “near universal coverage” and 35 “lower[ing] health insurance premiums,” 42 U.S.C. § 18091 (2)(D), (F), the ACA relies on three interrelated policies: insurance market reforms prohibiting insurers from denying coverage or charging…”
King v. Burwell, 135 S. Ct. 2480 (2015). · cites it 2× “" 42 U.S.C. § 18091 (2)(I). So Congress adopted a coverage requirement to "minimize this adverse selection and broaden the health insurance risk pool to include healthy individuals, which will lower health insurance premiums.”
California v. Texas, 593 U.S. 659 (2021). · cites it 2× “42 U. S. C. §18091 (2)(D). A major obstacle was the inability of many individuals to obtain adequate insurance due to the expensive medical care they were likely to require.”
Steven Hotze v. Sylvia Burwell, Sec'y H, 784 F.3d 984 (5th Cir. 2015). · cites it 5× “” 42 U.S.C. § 18091 (2)(D), (F). The Senate passed H.”
Seven-Sky v. Holder, 661 F.3d 1 (D.C. Cir. 2011). · cites it 4× “I therefore would vacate the judgment of the District Court and remand with directions that the suit be dismissed for lack of jurisdiction.”
Liberty Univ. v. Timothy Geithner, 671 F.3d 391 (4th Cir. 2011). · cites it 6× “42 U.S.C. § 18091 (a)(2)(F). To cope with these costs, hospitals increase the price of health care services, which in turn leads to rising health insurance premiums; Congress found that “[t]his cost-shifting increases family premiums by on average over $1,000 a year.”
Texas v. United States, 352 F. Supp. 3d 665 (N.D. Tex. 2018). · cites it 6× “" 42 U.S.C. § 18091 (2)(C). Congress made a policy decision that some individuals should not be subject to the penalty but should still be bound to satisfy their legal obligation to maintain minimum essential coverage.”
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— 42 U.S.C. § 18091(2)(A) — 1 case
Ass'n for Cmty. Affiliated Plans v. United States Dep't of Treasury (D.D.C. 2019).
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