Sixth Circuit Upholds PPACA’s Individual Mandate Against Intimate Association, Expressive Association, and Substantive Due Process Challenges

A non-profit national civic league and two of its members brought an action challenging the individual mandate provision of the Patient Protection and Affordable Care Act (PPACA). The individual mandate requires each individual to purchase a health insurance policy providing a minimum level of coverage or make a shared responsibility payment. 26 U.S.C. § 5000A (2010). The United States District Court for the Northern District of Ohio granted the government defendants' motion to dismiss in part and, subsequently, granted summary judgment in favor of the defendants.


The Sixth Circuit United States Court of Appeals affirmed the district court. First, the court held that the individual mandate did not infringe upon the individual plaintiffs' alleged right of intimate association with physicians. The court reasoned that even if the factors of smallness, selectivity, and seclusion of others exist to some degree in the plaintiffs' relationships with their doctors, those factors are not sufficient to establish a right to intimate association that should receive heightened scrutiny. The court found that relationships with large business enterprises like health insurance companies do not qualify as intimate associations warranting constitutional protection under the freedom of association. Moreover, nothing in the individual mandate provision of the PPACA precluded individuals from establishing relationships with the medical professionals of their choice, or required individuals to associate with particular medical professionals, in alleged violation of the right to intimate association.


Second, the Sixth Circuit held that the non-profit national civic league did not have a protected right to intimate association. The court based its holding on the league's size, purpose, policies, selectivity, and congeniality.


Third, the court held that the individual mandate did not violate the civic league's right of expressive association. The court reasoned that the league was free to voice its disapproval of the PPACA or health insurance in general; nothing about the statute affected the composition of the group by making group membership less desirable; and the league's members were not required to obtain health insurance and associate with health insurers at all, as they could choose to pay the shared responsibility payment instead.


Fourth, the court held that the individual mandate did not implicate the individuals' alleged fundamental due process liberty right to refuse unwanted medical care. The individual mandate required either the purchase of health insurance or the payment of a shared responsibility payment. The individuals remain free to choose their medical providers and the medical treatments they will or will not accept.


Finally, the court held that the individual mandate did not violate the individuals' substantive due process interest in avoiding disclosure of personal matters, such as private health information. The court reasoned that substantive due process protects an individual's interest in avoiding the disclosure of personal matters, such as private health information. However, not all statutes that require the disclosure of personal information are unconstitutional. The individual mandate does not actually compel the plaintiffs to disclose personal medical information to insurance companies. Plaintiffs could avoid any privacy concern altogether by simply foregoing insurance and complying with the individual mandate by making the shared responsibility payment.


See: U.S. Citizens Ass'n v. Sebelius, 2013 WL 380342 (C.A.6 (Ohio), February 1, 2013) (not designated for publication).