With oral arguments set for March 26-28 in the Supreme Court for the constitutionality of the Patient Protection and Affordable Care Act (PPACA), the court’s decision could have a significant effect on the 2012 presidential election since PPACA is already a hot-button issue, according to a perspective paper published online Feb. 29 in the New England Journal of Medicine.

“Public opinion, which favors some parts of the law but not others, makes the political calculus complicated,” wrote Gregory D. Curfman, MD, executive editor of NEJM, and colleagues. “With these factors in play, 2012 is shaping up to be a momentous year for U.S. healthcare.”

The legislation is set to impact approximately 32 million of the 50 million who are currently uninsured. Challenges to PPACA legislations will require the Supreme Court to apply the principle of federalism. With numerous suits filed against the PPACA, the court will address four questions.

First, the court will determine whether the Tax Anti-Injunction Act precludes review of the PPACA until after 2014. The Act provides that the legality of a tax cannot be challenged until the tax has been assessed.

If deemed appropriate, the court will then consider whether Congress has the authority to require most U.S. citizens to purchase health insurance or pay a penalty. “The government argues that it has such authority under the Constitution's Commerce Clause, which the Supreme Court has interpreted as providing Congress wide latitude to regulate activity that, when viewed cumulatively, has a substantial effect on interstate commerce,” the authors wrote.

If determined unconstitutional, the court will determine whether the rest of the PPACA must also be overturned or whether the mandate is “severable” from the rest of the law.

Finally, the court will consider whether the PPACA’s Medicaid expansion is constitutional and whether states can be required to comply with it in order to remain eligible for federal Medicaid funds. According to the authors, the principal point of contention is whether the PPACA requirements “commandeer” or “coerce” state functions in a way that exceeds federal authority.

“However the Supreme Court rules, the implications for healthcare in the U.S. will be profound,” the authors wrote. “At one extreme, the court could strike down the entire PPACA, implicitly endorsing a more limited role for the federal government in the regulation of healthcare and other areas. At the other extreme, the entire law could be upheld. Intermediate rulings, such as striking the mandate but upholding the Medicaid expansion, are of course also possible.”

Upholding of the PPACA would pressure providers to deliver more care, the authors concluded. “Currently, only about two-thirds of physicians accept Medicaid patients, so the burden of serving the newly eligible populations would fall disproportionately on these physicians. The PPACA begins to address this problem with workforce-development provisions. In addition, at least in the short run, healthcare costs would probably increase, though the PPACA contains some cost-control measures.”