Mead v. Holder

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLUMBIA
______________________________
MARGARET PEGGY LEE MEAD, )
et al., )
)
Plaintiffs, )
)
v. ) Civil Action No. 10-950 (GK)
)
ERIC H. HOLDER, JR., et al., )
)
Defendants. )
______________________________)

MEMORANDUM OPINION

Plaintiffs Margaret Peggy Lee Mead, Charles Edward Lee, Susan

Seven-Sky, Kenneth Ruffo, and Gina Rodriguez bring this action

against Defendants Eric H. Holder, Jr., Kathleen Sebelius, and

Timothy F. Geithner in their official capacities and Defendants

United States Department of Health and Human Services and United

States Department of the Treasury. Plaintiffs seek a declaration

pursuant to 28 U.S.C. §§ 2201-2202 that the individual insurance

mandate of the Patient Protection and Affordable Care Act, Pub. L.

No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care

and Education Reconciliation Act, Publ. L. No. 111-152, 124 Stat.

1029 (2010) (“Affordable Care Act” or “ACA”) is unconstitutional on

its face. Plaintiffs also seek injunctive relief against

enforcement of the mandate.

This matter is presently before the Court on Defendants’

Motion to Dismiss Plaintiffs’ Amended Complaint [Dkt. No. 15]
pursuant to Federal Rule of Civil Procedure 12(b)(6).1 On January

31, 2011, oral argument was heard on Defendants’ Motion. Upon

consideration of the Motion, Opposition, Reply, the arguments

presented by the parties in open court, and the entire record

herein, and for the reasons set forth below, the Motion to Dismiss

is granted.

The present litigation is one of many similar lawsuits

challenging the Affordable Care Act in United States District

Courts around the country. The controversy surrounding this

legislation is significant, as is the public’s interest in the

substantive reforms contained in the Act. It is highly likely that

a decision by the United States Supreme Court will be required to

resolve the constitutional and statutory issues which have been

raised. Needless to say, this Court’s personal views on the

1
In their August 20, 2010, Motion to Dismiss, Defendants
also moved for dismissal under Federal Rule of Civil Procedure
12(b)(1), arguing that Plaintiffs lacked standing, that this case
was not ripe for judicial review, and that this case was barred by
the Anti-Injunction Act, 26 U.S.C. § 7421. See Defs.’ Mot. at 9-16
[Dkt. No. 15]. On January 21, 2011, Defendants filed a Notice
stating that they do not intend to pursue their Rule 12(b)(1)
arguments. See Notice Regarding Mot. to Dismiss [Dkt. No. 34]. The
Court therefore will deem the Defendants’ arguments concerning the
Anti-Injunction Act waived and will not consider them. However,
because the parties cannot waive any defect in this Court’s
jurisdiction, the arguments concerning standing and ripeness will
still be addressed. See Ashcroft v. Iqbal, 129 S.Ct. 1937, 1945,
173 L.Ed.2d 868 (2009) (“Subject-matter jurisdiction cannot be
forfeited or waived and should be considered when fairly in
doubt.”) (citations omitted).

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necessity, prudence, or effectiveness of the Affordable Care Act

are of no moment whatsoever. The only issues concerning the ACA

presently before this Court are those raised by the parties:

namely, whether § 1501 passes muster under the Constitution of the

United States, and whether it violates the Religious Freedom

Restoration Act of 1993, 42 U.S.C. § 2000bb et seq. (“RFRA”).

I. Background

On March 23, 2010, President Barack Obama signed the

Affordable Care Act into law in an effort to curb rising health

care costs and to provide greater coverage for the more than 45

million Americans who were uninsured during 2009. See Cong. Budget

Office, Key Issues in Analyzing Major Health Insurance Proposals 1

(2008), available at http://www.cbo.gov/ftpdocs/99xx/

doc9924/12-18-keyissues.pdf. The ACA contains many provisions

designed to improve access to the national health care market,

reduce health care costs, and increase coverage for those who now

lack protection. For example, the ACA (1) creates state-operated

health benefit exchanges which enable individuals and small

businesses to obtain price-competitive health insurance, see ACA §§

1311, 1321, (2) expands Medicaid coverage, see ACA § 2001, (3)

prohibits insurance companies from denying or increasing the price

of coverage to individuals with pre-existing medical conditions,

from limiting the amount of coverage available, and from rescinding

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coverage when an individual becomes sick, see ACA §§ 1001, 1201,

(4) requires that large employers offer health insurance to their

employees, see ACA § 1511, and (5) waives all Medicare coinsurance

and copayment fees for a multitude of preventive services,

including screening for depression, colon cancer, breast cancer,

and cervical cancer, see ACA § 4104.

Plaintiffs challenge § 1501 of the Affordable Care Act,

entitled “Requirement to Maintain Minimum Essential Coverage.” See

ACA § 1501 (adding 26 U.S.C. § 5000A) (“individual mandate”); id.

§ 10106 (amending findings in § 1501). Section 1501 requires

“individuals,” as defined under the ACA,2 “for each month beginning

after 2013 [to] ensure that the individual, and any dependent of

the individual who is an applicable individual, is covered under

minimum essential coverage for such month.” 26 U.S.C. § 5000A(a).

If an individual fails to obtain such minimum essential coverage,

he or she must include with their annual federal tax payment a

2
Under the ACA, the term “individual” excludes those who
qualify for a religious conscience exemption under § 1311(d)(4)(H),
are members of a health care sharing ministry, or are incarcerated.
26 U.S.C. § 5000A(d). In addition, § 1501 exempts from its penalty
provision those individuals for whom the annual cost of the
required coverage exceeds eight percent of their household income,
individuals whose household income falls below the poverty line,
members of Indian tribes, and individuals deemed to have suffered
a hardship with respect to their capability to obtain coverage. Id.
§ 5000A(e).

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“shared responsibility payment,” which is a “penalty” consisting of

a fixed dollar amount. Id. §§ 5000A(b), (c).

In short, § 1501 establishes a requirement that, beginning in

2014, each individual obtain health care coverage or pay a monetary

penalty. This individual mandate is a critical element in

Congress’s comprehensive plan to reduce the spiraling health care

costs that this country has experienced and is expected to

experience in the future. Indeed, Congress specifically concluded

that “[t]he 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 preexisting

conditions can be sold.” ACA § 1501(a)(2)(I), as amended by §

10106. Thus, the individual mandate provision must be viewed not as

a stand-alone reform, but as one piece of a larger package of

reforms meant to revamp the national health care market by creating

new procedures and institutions to reduce overall costs. See ACA §

1501(a)(2)(H), as amended by § 10106. Put differently, many of the

reforms contained in the Affordable Care Act rely on the individual

mandate--or, more specifically, the reduction in health insurance

premiums that the mandate is intended to produce--to help support

their own financial viability.

Plaintiffs are individual federal taxpayers who specifically

allege that they can afford health insurance coverage, but that

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they have chosen not to purchase it in the past and do not wish to

purchase it in the future. Plaintiff Mead is a sixty-two year-old,

self-employed resident of North Carolina who has not had health

insurance for approximately eighteen years. Am. Compl. ¶¶ 11-14

[Dkt. No. 10]. Plaintiff Lee is a sixty year-old, unemployed

resident of Texas who has not had health insurance for

approximately twenty-two years, although he could obtain coverage

under the plan held by his wife, who is employed. Id. ¶¶ 23-26.

Plaintiff Seven-Sky is a fifty-three year-old, self-employed

resident of New York who has not had health insurance for at least

six years. Id. ¶¶ 37-39. Plaintiff Ruffo is a forty-nine year-old,

self-employed resident of Texas who has not had health insurance

for at least five years. Id. ¶¶ 51-54. Finally, Plaintiff Rodriguez

is a thirty-six year-old resident of Texas who is a stay-at-home

mother of three children and who has not had health insurance for

approximately ten years. Id. ¶¶ 63-75.

According to Plaintiffs, they are all “generally in good

health.” Id. ¶¶ 12, 25, 39, 53, 65. While Plaintiffs Ruffo and

Rodriguez do intend to consume medical services in the future, they

object to § 1501 because they would prefer to pay for those

services out of pocket. Plaintiffs Mead, Lee, and Seven-Sky, on the

other hand, allege that they will continue to refuse all medical

services for the remainder of their lives.

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 None of the Plaintiffs currently qualify for Medicare or

Medicaid, and Plaintiffs Mead, Lee, and Seven-Sky have stated that

they will not enroll in Medicare once they do qualify. Id. ¶¶ 11,

24, 38, 52, 64. Plaintiffs contend that they also do not qualify

for any of the exemptions under the ACA, and that it is thus

“highly likely” that they will be required to either purchase

health insurance or make an annual shared responsibility payment

beginning in 2014. Id. ¶¶ 14, 27, 41, 55, 67.

Plaintiffs strenuously object to the Act’s individual mandate

because they believe that the federal government lacks the

constitutional authority to require them either to purchase health

insurance or pay a substantial penalty. According to Plaintiffs,

the individual mandate provision will impose annual shared

responsibility payments through 2020 costing Plaintiffs Mead, Lee,

Seven-Sky, and Ruffo a minimum of $3,895 each and Plaintiff

Rodriguez a minimum of $11,685, for a total cost to Plaintiffs of

$27,265 in this period. Plaintiffs claim that anticipation of these

costs has compelled them to “adjust their fiscal affairs” in the

present. Id. ¶ 4.

Plaintiffs also object to the individual mandate on religious

grounds. Plaintiffs Mead, Lee, and Seven-Sky believe that God will

provide for their physical, spiritual, and financial well-being,

and that “[b]eing forced to buy health insurance conflicts with

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[their] religious faith because [they] believe[] that [they] would

be indicating that [they] need[] a backup plan and [are] not really

sure whether God will, in fact, provide for [their] needs.” Id. ¶¶

16, 29, 43. Plaintiffs Ruffo and Rodriguez do not wish to purchase

health insurance because it is contrary to their beliefs in a

holistic approach to medicine. Id. ¶ 56, 68. Rodriguez specifically

objects on the ground that health insurance would not cover many of

the medical services and health products she currently pays for out

of pocket.3 Id. ¶ 69.

Based on these objections, Plaintiffs assert in their Amended

Complaint that the Act’s individual mandate and its related

enforcement provisions exceed Congress’s power under Article I of

the Constitution and, consequently, that these provisions are

unconstitutional and unenforceable. In the alternative, Plaintiffs

argue that the individual mandate violates their rights as set

forth in RFRA.

On August 20, 2010, Defendants filed the present Motion to

Dismiss under Federal Rule of Civil Procedure 12(b)(6).4 The

Government argues that the Amended Complaint fails to state a claim

3
Plaintiff Rodriguez does not specify which services that
she currently pays for out of pocket would not be covered by health
insurance.
4
As noted earlier, Defendants have, for all practical
purposes, withdrawn their Motion to Dismiss under Rule 12(b)(1).
See supra n.1.

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because Congress does have authority under the Commerce Clause and

the General Welfare Clause of Article I of the Constitution to

enact § 1501, and because § 1501 does not violate RFRA.

II. Standard of Review

Under Rule 12(b)(6), a plaintiff need only plead “enough facts

to state a claim to relief that is plausible on its face” and to

“nudge[] [his or her] claims across the line from conceivable to

plausible.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570, 127

S.Ct. 1955, 167 L.Ed.2d 929 (2007). “[A] complaint [does not]

suffice if it tenders naked assertions devoid of further factual

enhancement.” Iqbal, 129 S.Ct. at 1949 (internal quotations

omitted) (citing Twombly, 550 U.S. at 557, 127 S.Ct. 1955).

Instead, the complaint must plead facts that are more than “merely

consistent with” a defendant’s liability; “the pleaded factual

content [must] allow[] the court to draw the reasonable inference

that the defendant is liable for the misconduct alleged.” Id. at

1940.

“[O]nce a claim has been stated adequately, it may be

supported by showing any set of facts consistent with the

allegations in the complaint.” Twombly, 550 U.S. at 563, 127 S.Ct.

1955. Under the standard set forth in Twombly, a “court deciding a

motion to dismiss must . . . assume all the allegations in the

complaint are true (even if doubtful in fact) . . . [and] must give

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the plaintiff the benefit of all reasonable inferences derived from

the facts alleged.” Aktieselskabet AF 21. November 2001 v. Fame

Jeans Inc., 525 F.3d 8, 18 (D.C. Cir. 2008) (internal quotations

marks and citations omitted); see also Tooley v. Napolitano, 586

F.3d 1006, 1007 (D.C. Cir. 2009) (declining to reject or address

the government’s argument that Iqbal invalidated Aktieselskabet).

Of course, if a claim does not rest on sound legal conclusions, it

does not state “a plausible claim for relief,” regardless of the

facts alleged. Iqbal, 129 S.Ct. at 1950.

III. Analysis

The Court will first address its subject matter jurisdiction

over this case, before turning to the parties’ legal arguments

concerning Plaintiffs’ substantive claims.

A. Article III Subject Matter Jurisdiction

On January 21, 2011, Defendants gave notice to this Court of

their intent not to pursue their arguments that the Amended

Complaint should be dismissed under Federal Rule of Civil Procedure

12(b)(1) for lack of subject matter jurisdiction. Although

Defendants have waived these arguments, every federal court must

satisfy itself of its own subject matter jurisdiction, which is

limited by Article III of the Constitution. See FW/PBS, Inc. v.

Dallas, 493 U.S. 215, 230-31, 110 S.Ct. 596, 107 L.Ed.2d 603

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(1990). Therefore, this Court must determine whether it has

jurisdiction.

Article III of the United States Constitution limits federal

jurisdiction to actual cases and controversies. “Three

inter-related judicial doctrines--standing, mootness, and ripeness-

-ensure that federal courts assert jurisdiction only over” such

disputes. Worth v. Jackson, 451 F.3d 854, 855 (D.C. Cir. 2006). Two

of those doctrines formerly asserted by Defendants, standing and

ripeness, have been the topic of extended discussion in the

district court opinions deciding motions to dismiss in similar

challenges to the ACA made across the country,5 and will now be

considered in the context of this case.

5
See Goudy-Bachman v. United States Dep’t of Health and
Human Svs., No. 10-cv-763, 2011 WL 223010, at *4-8 (M.D. Pa. Jan.
24, 2011); New Jersey Physicians, Inc. v. Obama, No. 10-cv-1489,
2010 WL 5060597, at *3-8 (D.N.J. Dec. 8, 2010); Liberty Univ., Inc.
v. Geithner, No. 6:10-cv-00015, 2010 WL 4860299, at *3-8 (W.D. Va.
Nov. 30, 2010); State of Florida ex rel. McCollum v. United States
Dep’t of Health and Human Servs., 716 F.Supp.2d 1120, 1144-50 (N.D.
Fla. 2010); Thomas More Law Ctr. v. Obama, 720 F.Supp.2d 882, 887-
90 (E.D. Mich. 2010); United States Citizens Ass’n v. Sebelius, No.
10-cv-1065, 2010 WL 4947043, at *3-5 (N.D. Ohio Nov. 22, 2010);
Baldwin v. Sebelius, No. 10-cv-1033, 2010 WL 3418436, at *1-5 (S.D.
Cal. Aug. 27, 2010); see also Virginia ex rel. Cuccinelli v.
Sebelius, 702 F.Supp.2d 598, 602-08 (E.D. Va. 2010) (discussing
standing and ripeness in challenge brought by Commonwealth of
Virginia, rather than any individual plaintiffs).

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 1. Standing

In Lujan v. Defenders of Wildlife, the Supreme Court

established the following three requirements for Article III

standing:

First, the plaintiff must have suffered an
injury in fact-an invasion of a legally
protected interest which is (a) concrete and
particularized, and (b) actual or imminent,
not conjectural or hypothetical. Second, there
must be a causal connection between the injury
and the conduct complained of--the injury has
to be fairly ... trace[able] to the challenged
action of the defendant, and not ... th[e]
result [of] the independent action of some
third party not before the court. Third, it
must be likely, as opposed to merely
speculative, that the injury will be redressed
by a favorable decision.

504 U.S. 555, 560-61, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992)

(internal quotations and citations omitted). In this case, the

issues regarding standing relate only to the first element, namely

the requirement that Plaintiffs suffer an injury in fact.

Plaintiffs allege two separate injuries arising from the

individual mandate provision of the ACA in their Amended Complaint.

First, Plaintiffs allege a future injury based on the Act’s

requirement that, beginning in 2014, they make annual shared

responsibility payments for having failed to obtain minimum

essential coverage. Second, Plaintiffs allege that the ACA is

causing actual injury now by forcing them to rearrange their

finances at this time in order to prepare for enforcement of the

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individual mandate in 2014. The question before this Court is

whether either of these claimed injuries establishes Plaintiffs’

standing in this case.

a. Future Injury

The Court will first consider whether Plaintiffs’ alleged

threat of future injury in the form of shared responsibility

payments is “actual or imminent,” and not “conjectural and

hypothetical.” Id. at 560, 112 S.Ct. 2130 (internal quotations and

citations omitted). Specifically, the Court must decide whether

Plaintiffs have demonstrated that the individual mandate will apply

to them in 2014, given the possibility that intervening events

could result in their exemption from the minimum coverage

requirement. Of course, if Plaintiffs are found to be exempt from

the minimum coverage requirement in 2014, their claimed injury--

payment of the penalty--will not occur.

For example, Plaintiff Mead may not be subject to the

individual mandate in 2014 because she will likely be eligible for

Medicare Part A by that time. See Defs.’ Mot. at 11 (“Plaintiff

Mead . . . will likely be subject to automatic entitlement to

Medicare Part A by 2014, thus satisfying the minimum coverage

requirement.”). In addition, the other Plaintiffs “might find

employment by 2014 that provides adequate health [care] coverage,

find that their economic situation has deteriorated to the point

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where they qualify for Medicaid or a financial hardship exemption,

or discover that they have changed their minds about the necessity

of health insurance due to such possible life events as a serious

illness.” Id. at 11-12 (internal citation and footnote omitted). In

short, the argument is that the facts alleged in the Amended

Complaint may change between now and 2014, and therefore this Court

risks “deciding a case in which no injury would have occurred at

all.” Lujan, 504 U.S. at 564 n.2, 112 S.Ct. 2130.

Section 1501 of the ACA provides that Medicare Part A will

satisfy the minimum coverage requirement. See 26 U.S.C. §

5000A(f)(1)(A). Thus, if Plaintiff Mead is covered under Medicare

Part A in 2014, it appears that she would not be subject to the

Act’s penalty provision. However, Mead alleges that she will

nevertheless refuse to enroll in Medicare once she qualifies.

The Social Security Act provides that “[e]very individual who

has attained age 65 and is entitled to monthly [Social Security]

benefits . . . shall be entitled to hospital insurance benefits

under Part A of [the Medicare Act].” 42 U.S.C. § 426(a). To be

entitled to Social Security benefits, Mead must file an

application. See 42 U.S.C. § 402. If Mead does apply for Social

Security benefits, her enrollment in Medicare Part A becomes

automatic. In addition, she may not opt out of Medicare Part A and

still maintain her Social Security benefits; if she chooses to

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maintain her Social Security benefits, she will remain enrolled in

Medicare Part A. See Social Security Administration, POMS Section

HI 00801.002 Waiver of HI Entitlement by Monthly Beneficiary,

available at http://policy.ssa.gov/poms.nsf/lnx/0600801002; Hall v.

Sebelius, 689 F.Supp.2d 10, 15-16 (D.D.C. 2009) (rejecting in part

a challenge to Social Security Administration requirement that

individuals who receive Social Security benefits must also receive

Medicare Part A coverage).

The Amended Complaint states that Mead will refuse to enroll

in Medicare Part A, but it does not allege that she will forgo her

Social Security benefits. See Am. Compl. ¶ 11. In the absence of

such an allegation, the Court is not persuaded that there is a

substantial probability that she will reject her monthly Social

Security checks and therefore not be covered under Medicare Part A

in 2014. Thus, it is unlikely that Plaintiff Mead will be subject

to § 1501’s penalty provision in 2014, which compels the conclusion

that she lacks standing in this case.

Still, if just one of the other Plaintiffs has standing to

raise the claims alleged in the Amended Complaint, this Court has

subject matter jurisdiction. Watt v. Energy Action Educ. Found.,

454 U.S. 151, 160, 102 S.Ct. 205, 70 L.Ed.2d 309 (1981). As

discussed above, the other Plaintiffs’ circumstances could also

change before 2014 so that they either are no longer subject to the

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minimum essential coverage requirement or they satisfy it. However,

this Court agrees with Judge Vinson in McCollum that:

Such ‘vagaries’ of life are always present, in
almost every case that involves a pre-
enforcement challenge. If the defendants’
position were correct, then courts would
essentially never be able to engage in pre-
enforcement review. Indeed, it is easy to
conjure up hypothetical events that could
occur to moot a case or deprive any plaintiff
of standing in the future.

McCollum, 716 F.Supp.2d at 1147 (emphasis in original). Indeed, as

our Court of Appeals has made clear, a plaintiff need only

establish the elements of standing by a “substantial probability,”

not with certainty. Sierra Club v. EPA, 292 F.3d 895, 899 (D.C.

Cir. 2002).

The possible changes in the facts of this case are by no means

certain, or even likely to occur. By the same token, there is a

substantial probability that Plaintiffs will remain subject to 26

U.S.C. § 5000A(a) in 2014. In addition, whether Plaintiffs will be

subject to the individual mandate in the future does not depend on

such future contingencies as third-party actions. This case is

therefore distinguishable from cases in which the alleged future

injuries are truly speculative. See, e.g., Public Citizen, Inc. v.

NHTSA, 489 F.3d 1279, 1290 (D.C. Cir. 2007);6 Gulf Restoration

6
In Public Citizen, four individual tire manufacturers, a
tire industry trade association, and an organization advocating for
consumer safety challenged a National Highway Traffic Safety

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Network, Inc. v. Nat’l Marine Fisheries Serv., 730 F.Supp.2d 157,

165-67 (D.D.C. 2010). Consequently, Plaintiffs have alleged facts

sufficient to show a substantial probability that they will remain

without health insurance coverage in 2014 and that they will

thereafter be required by the ACA to make annual shared

responsibility payments.

A separate issue, however, is whether Plaintiffs’ alleged

future injury is imminent. It first bears noting that, unlike the

plaintiffs in Lujan, Plaintiffs in this case have given a definite

point in time by which their injury will occur, namely 2014, the

effective date of the Act’s individual mandate provision. Thus,

injury is not alleged at “some indefinite future time,” which would

indicate a lack of imminence. Lujan, 504 U.S. at 2139 n.2, 112

S.Ct. 2130.

Administration performance standard for tire pressure monitors. See
489 F.3d 1279. The standard imposed no requirements upon any of
those petitioners, but only on automobile manufacturers, none of
whom were a party to the lawsuit. The petitioners’ claimed injuries
instead arose from an alleged increased risk of car accidents. The
court rejected the tire industry petitioners’ “increased-risk-of-
harm” claim, concluding that such injury was speculative because it
turned on both the occurrence of an accident and the victim’s
subsequent decision to bring a product liability claim against tire
manufacturers. However, the court did not close the door to the
organization’s increased-risk-of-harm claim, but sought further
information that would demonstrate “at least both (i) a
substantially increased risk of harm and (ii) a substantial
probability of harm with that increase taken into account.” Id. at
1296 (emphasis in original).

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 Still, Plaintiffs’ alleged injuries are temporally remote. In

McConnell v. FEC, the Supreme Court concluded that an FEC

regulation which would not affect the plaintiff Senator until five

years in the future was “too remote temporally to satisfy Article

III standing.” 540 U.S. 93, 226, 124 S.Ct. 619, 157 L.Ed.2d 491

(2003); see also Shays v. FEC, 414 F.3d 76, 122-23 (D.C. Cir. 2005)

(noting that directly regulated parties do not have automatic

standing absent showing of imminent injury). Thus, McConnell

suggests that an injury which is several years in the future may

not be imminent, and therefore insufficient to establish standing.

As the Court noted in Lujan, however, imminence is an “elastic

concept” that does not lend itself to mathematical precision.

Lujan, 504 U.S. at 564 n.4, 112 S.Ct. 2130. In addition, it is

significant that our Circuit held, in a case decided shortly after

McConnell,7 that temporal remoteness alone does not automatically

defeat standing. In Village of Bensenville v. FAA, our Court of

7
Although the threatened injury in Village of Bensenville
was significantly more remote than that in McConnell, the court
never cited McConnell in its opinion. See Village of Bensenville v.
FAA, 376 F.3d 1114 (D.C. Cir. 2004). It is hard to believe that the
Court of Appeals was not fully aware of that decision. One possible
reason for this omission is that, in Village of Bensenville, the
FAA had made a final decision to approve the challenged fees. Thus,
the fee’s application to plaintiffs was nearly certain, although it
was many years in the future. Id. at 1119. In contrast, in
McConnell, it was not as clear that the challenged regulation would
apply to the plaintiff, as its application depended on a number of
factors such as the plaintiff’s decision to seek re-election. 540
U.S. at 226, 124 S.Ct. 619.

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Appeals found standing where the plaintiffs were challenging a fee

scheduled to be collected thirteen years in the future because

“[t]he FAA’s order is final and, absent action by us, come 2017

Chicago will begin collecting the passenger facility fee;

accordingly, ‘the impending threat of injury [to the

municipalities] is sufficiently real to constitute injury-in-fact

and afford constitutional standing.’” 376 F.3d 1114, 1119 (D.C.

Cir. 2004) (quoting Wyo. Outdoor Council v. United States Forest

Serv., 165 F.3d 43, 51 (D.C. Cir. 1999)). In this case, the ACA’s

individual mandate provision is similarly final and, absent action

by the courts or Congress, the federal government will begin to

impose penalties on qualifying individuals who refuse to obtain

minimum essential coverage in 2014.

Although it cannot be said with absolute certainty that

Plaintiffs will qualify as individuals subject to the minimum

essential coverage requirement in 2014, such a conclusion is not

required. All that is required is that Plaintiffs allege a

substantial probability that they will be subject to the ACA’s

requirement to maintain minimum essential coverage in 2014. Sierra

Club, 292 F.3d at 899 (stating that plaintiff need not prove merits

of case, but only demonstrate that there is a “substantial

probability that local conditions will be adversely affected and

thereby injure a member of the organization”) (citation and

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internal quotations omitted). Because the Court finds that

Plaintiffs have met this standard, it concludes that they have

demonstrated a concrete, particularized, and imminent future

injury: payment of a penalty under 26 U.S.C. § 5000A(b) for having

failed to satisfy section § 5000A(a)’s requirement.

b. Actual Injury

As noted above, in addition to alleging future injury,

Plaintiffs also allege actual injury: the requirement that they

adjust their finances now by setting aside money to pay the

anticipated penalties. It is established that the taking of current

measures to ensure future compliance with a statute can constitute

an injury: “The present or near-future costs of complying with a

statute that has not yet gone into effect can be an injury in fact

sufficient to confer standing.” Liberty Univ., 2010 WL 4860299, at

*5 (discussing Virginia v. Am. Booksellers Ass’n, Inc., 484 U.S.

383, 392-93, 108 S.Ct. 636, 98 L.Ed.2d 782 (1988)).

Indeed, as Plaintiffs allege in their Amended Complaint, being

forced to set aside money now prevents them from using that money

for discretionary spending, charitable donations, or paying debts,

thus requiring them to “adjust [their] lifestyle[s] accordingly.”

Am. Compl. ¶¶ 20, 34, 48, 60, 73. For example, Plaintiff Rodriguez

specifically alleges that she is prevented from saving money for

her children’s college education because she must set aside funds

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now in order to pay the Act’s penalties. Id. ¶ 73. As this example

demonstrates, a burden is placed on those individuals who

anticipate being subject to the Act’s individual mandate penalty.

Plaintiffs have therefore suffered an injury in fact.

To summarize, then, Plaintiffs have alleged two distinct

injuries: (1) a future injury fairly traceable to the enforcement

of the ACA beginning in 2014, when they are forced to make annual

shared responsibility payments, and (2) a present injury resulting

from their needing to rearrange their finances now in anticipation

of those mandatory payments. Plaintiffs therefore have demonstrated

their Article III standing to bring this challenge to the ACA.

2. Ripeness

Next, this Court will consider whether it lacks subject matter

jurisdiction over Plaintiffs’ challenge because the case is not yet

ripe for review. Like the Article III case and controversy

requirements for standing, a plaintiff must suffer present or

imminent injury in fact to establish Constitutional ripeness. See

Wyo. Outdoor Council, 165 F.3d at 48 (“Just as the constitutional

standing requirement for Article III jurisdiction bars disputes not

involving injury-in-fact, the ripeness requirement excludes cases

not involving present injury.”). “If a threatened injury is

sufficiently ‘imminent’ to establish standing, the constitutional

requirements of the ripeness doctrine will necessarily be

-21-
satisfied. At that point, only the prudential justiciability

concerns of ripeness can act to bar consideration of the claim.”

Nat’l Treasury Employees Union v. United States, 101 F.3d 1423,

1428 (D.C. Cir. 1996).

Having found both a present injury and a sufficiently imminent

threatened injury to establish Plaintiffs’ standing in this case,

the Court next considers the doctrine of prudential ripeness.

Courts apply a two-pronged balancing test to determine whether a

case is ripe for adjudication. See Abbott Laboratories v. Gardner,

387 U.S. 136, 149, 87 S.Ct. 1507, 18 L.Ed.2d 681 (1967). First, a

court must evaluate the “fitness of the issue for judicial

decision.” Id. Second, a court must consider “the hardship to the

parties of withholding [its] consideration.” Id.

A case is fit for judicial resolution when it does not depend

upon “contingent future events that may not occur as anticipated,

or indeed may not occur at all.” Thomas v. Union Carbide Agric.

Prods. Co., 473 U.S. 568, 580-81, 105 S.Ct. 3325, 87 L.Ed.2d 409

(1985). The possibility of intervening changes in Plaintiffs’

circumstances which would exempt them from the individual mandate

provision has been noted, but once again it does not persuade this

Court that Plaintiffs’ case is nonjusticiable:

[A] litigant seeking shelter behind a ripeness
defense must demonstrate more than a
theoretical possibility that harm may be
averted. The demise of a party or the repeal

-22-
 of a statute will always be possible in any
case of delayed enforcement, yet it is well
settled that a time delay, without more, will
not render a claim of statutory invalidity
unripe if the application of the statute is
otherwise sufficiently probable.

Riva v. Com. of Mass., 61 F.3d 1003, 1011 (1st Cir. 1995)

(citations omitted). For the reasons already given, the application

of the individual mandate to at least one of the Plaintiffs is

sufficiently probable that the delay in its enforcement does not

render their claims unripe.

In addition, Plaintiffs have also alleged a ripe, actual

injury consisting of the impact on their current financial

decision-making. That injury is being felt now, and is therefore

not subject to contingent future events. Finally, the issues

presented in this case are overwhelmingly legal, and it is well

established that cases involving only purely legal issues are more

fit for immediate review than those with key unresolved factual

issues. Abbott Laboratories, 387 U.S. at 149, 87 S.Ct. 1507.

In short, the facts as alleged show that “there is a

substantial controversy, between parties having adverse legal

interests, of sufficient immediacy and reality to warrant the

issuance of a declaratory judgment.” Maryland Cas. Co. v. Pacific

Coal & Oil Co., 312 U.S. 270, 273, 61 S.Ct. 510, 85 L.Ed. 826

(1941). The Court therefore concludes that this case is fit for

judicial resolution.

-23-
 With respect to the hardship prong, it is clear that the

individual mandate provision has “a direct effect on the day-to-day

business” of Plaintiffs. Abbott Laboratories, 387 U.S. at 152, 87

S.Ct. 1507. Plaintiffs must restructure their finances either to

buy unwanted health insurance or to put aside money for future

penalties. Pls.’ Opp’n at 7. Thus, if this Court were to delay

consideration of Plaintiffs’ challenge, they would have to choose

between using their money for other purposes now and risking their

inability to pay future penalties under the Affordable Care Act, or

needlessly saving money in the interim that could have been put to

different uses. See Riva, 61 F.3d at 1012 (concluding that hardship

prong was satisfied when plaintiff challenging future pension

reduction would be forced, in absence of judicial review, to guess

whether his benefits would not be reduced--thus finding himself

inadequately prepared if they were--or whether they would be --thus

needlessly “depriv[ing] himself in the intervening seven years”).

For these reasons, the Court concludes that the present case

is fit for judicial review and that delaying its review would

result in further hardship to Plaintiffs.8 Consequently, the Court

8
Apart from the hardship which delaying resolution of this
case would impose on Plaintiffs, “it certainly appears that the
government has an interest in knowing sooner, rather than later,
whether an essential part of its program regulating the national
health care market is constitutional, although in this case it is
not the government asking for the review.” Thomas More Law Ctr.,
720 F.Supp.2d at 890. In addition, as a practical matter, other

-24-
holds that it has subject matter jurisdiction over Plaintiffs’

case.

B. Congress’s Authority for Enacting the Individual Mandate

Having determined that it has subject matter jurisdiction, the

Court now turns to the parties’ substantive arguments concerning

the constitutionality of the ACA. Article I of the Constitution

establishes that the legislative branch of the federal government

shall be one of enumerated--and therefore limited--powers. See U.S.

Const. art. I, § 8. Pursuant to the Tenth Amendment, any powers not

granted to the federal government and not prohibited to the states

by the Constitution are reserved to the states and to the people.

U.S. Const. amend. X. By maintaining this separation between the

federal government and the states, the far-seeing Framers of our

Constitution intended to “‘reduce the risk of tyranny and abuse

from either front.’” United States v. Lopez, 514 U.S. 548, 552, 115

S.Ct. 1624, 131 L.Ed.2d 626 (1995) (quoting Gregory v. Ashcroft,

501 U.S. 452, 458, 111 S.Ct. 2395, 115 L.Ed.2d 410 (1991)).

Plaintiffs seek a declaration that § 1501 is unconstitutional

on the basis that Congress exceeded its constitutional powers when

it required individuals to either purchase health insurance or pay

actors in the health care market who are not parties to this
litigation but must take significant steps to adapt to the ACA’s
reforms--including hospitals, doctors, and, of course, insurance
companies--have a substantial interest in knowing whether the ACA
passes constitutional muster.

-25-
a penalty. Because Plaintiffs are mounting a facial challenge to

the ACA, they must satisfy the demanding requirement to demonstrate

that “no set of circumstances exist under which the Act would be

valid.” United States v. Salerno, 481 U.S. 739, 745, 107 S.Ct.

2095, 95 L.Ed.2d 697 (1987). The Government moves for dismissal of

Plaintiffs’ challenge on the basis that it fails to state a claim

because Article I, § 8 delegates to Congress the power to enact the

individual mandate provision under the Commerce Clause, the

Necessary and Proper Clause, and the General Welfare Clause. The

Court will consider each of these claimed authorities for § 1501 in

turn.

1. Commerce Clause

Article I, § 8 of the Constitution delegates to Congress the

power “[t]o regulate Commerce with foreign Nations, and among the

several States, and with the Indian Tribes.” The earliest judicial

pronouncement setting forth the breadth of the Commerce Clause was

issued by Chief Justice Marshall in Gibbons v. Ogden, 9 Wheat. 1,

196, 6 L.Ed. 23 (1824), where he described it as “the power to

regulate; that is, to prescribe the rule by which [interstate]

commerce is to be governed.”

Since Chief Justice Marshall’s pronouncement, the Commerce

Clause has greatly evolved as the country’s economic system has

become ever more dominated by commerce “among the several States.”

-26-
In the first century of the United States’s history, Congress used

its Commerce Clause power primarily to ensure the survival of the

federal republic by preventing the states from engaging in economic

competition with one another. Thus, the earliest judicial decisions

focused “almost entirely [on] the Commerce Clause as a limit on

state legislation that discriminated against interstate commerce.”

Lopez, 514 U.S. at 553-54, 115 S.Ct. 1624. However, by the turn of

the 20th century the Court’s focus shifted to examining the extent

of Congress’s positive power to regulate, beginning with the

enactment of--and subsequent challenges to--two major pieces of

legislation: the 1887 Interstate Commerce Act, 24 Stat. 379, and

the 1890 Sherman Antitrust Act, 26 Stat. 209, as amended, 15 U.S.C.

§ 1 et seq. See id.; State of Florida ex rel. Bondi, 2011 WL

285683, at *14-15.

Following this shift in focus, the Supreme Court’s

interpretation of Congress’s Commerce Clause power began to evolve

in a line of cases decided in the 20th century. Because these cases

established a number of basic principles applicable to this case,

a brief discussion of them is necessary before turning to an

analysis of the parties’ specific arguments.

a. Long-Standing Principles of Commerce Clause
Jurisprudence

In the early 20th century, when the focus of Commerce Clause

jurisprudence was only beginning to shift toward Congress’s power

-27-
to regulate, the Court’s interpretation of this power was quite

narrow. Famously, in A.L.A. Schechter Poultry Corp. v. United

States, 295 U.S. 495, 550, 55 S.Ct. 837, 79 L.Ed. 1570 (1935), the

Court struck down regulations determining employee hours and wages

because such intrastate employment related only “indirectly” to

interstate commerce.

However, beginning with a case decided in 1937, NLRB v. Jones

& Laughlin Steel Corp., the Court’s interpretation of the Commerce

Clause power expanded to include regulation of those purely

intrastate activities which have a substantial effect, whether

direct or indirect, on interstate commerce. 301 U.S. 1, 36-37, 57

S.Ct. 615, 81 L.Ed. 893 (1937); see also United States v. Darby,

312 U.S. 100, 119-21, 61 S.Ct. 451, 85 L.Ed. 609 (1941)

(reaffirming that Congress may regulate intrastate activities which

affect interstate commerce); Lopez, 514 U.S. at 559, 115 S.Ct. 1624

(clarifying that activities must “substantially” affect interstate

commerce to fall within the Commerce Clause power). In the seminal

case of Perez v. United States, the Court therefore identified

three strands of Commerce Clause power: (1) the power to regulate

the channels of interstate commerce, (2) the power to protect the

instrumentalities of interstate commerce and persons or things in

its stream, and (3) the power to regulate activities substantially

affecting interstate commerce. 402 U.S. 146, 150, 91 S.Ct. 1357,

-28-
1359, 28 L.Ed.2d 686 (1971). Defendants rely on this third

category--the power to regulate activities substantially affecting

interstate commerce--to argue that § 1501 falls within the well

established parameters of the Commerce Clause.

In the wake of Jones & Laughlin Steel and Darby, several

Commerce Clause cases have further explained this third strand of

Congress’s power. The earliest relevant case is Wickard v. Filburn,

317 U.S. 111, 63 S.Ct. 82, 87 L.Ed. 122 (1942), where a plaintiff

wheat farmer challenged a penalty imposed on him pursuant to the

Agricultural Adjustment Act of 1938 for harvesting wheat in excess

of the amount allotted to him. The farmer alleged that the excess

wheat was grown only for his personal consumption, and thus

Congress lacked power under the Commerce Clause to impose the

penalty because his activity was both local and non-commercial in

nature.

The Supreme Court disagreed, concluding that the wheat

“supplies a need of the man who grew it which would otherwise be

reflected by purchases in the open market . . . .” Id. at 128, 63

S.Ct. 82. In other words, the wheat grown for personal consumption

was found to distort the interstate wheat market by eliminating the

demand of the farmer, who would otherwise be forced to purchase it

on the open market. This effect was sufficient for Congress to step

-29-
in and prevent the farmer from harvesting wheat for personal

consumption under its Commerce Clause power.

In reaching this conclusion, Wickard established two basic

principles which are particularly applicable to this case. First,

the Court held that “even if appellee’s activity be local and

though it may not be regarded as commerce, it may still, whatever

its nature, be reached by Congress if it exerts a substantial

economic effect on interstate commerce . . . .” Id. at 125, 63

S.Ct. 82. Wickard therefore signals that the prime focus of the

Commerce Clause inquiry is the activity’s effect on interstate

commerce, not whether it is local or commercial.

Second, the Court held that the fact “[t]hat appellee’s own

contribution to the demand for wheat may be trivial by itself is

not enough to remove him from the scope of federal regulation

where, as here, his contribution, taken together with that of many

others similarly situated, is far from trivial.” Id. at 128, 63

S.Ct. 82. Put differently, an individual’s activities may fall

within the reach of Congress’s Commerce Clause power even if, when

considered alone, the effect on interstate commerce is negligible,

so long as such activities, in the aggregate, have a substantial

effect on such interstate commerce. Thus, courts may not “excise,

as trivial, individual instances of the class,” but must look to

whether the larger class of activities regulated by Congress

-30-
substantially affects interstate commerce. Perez, 402 U.S. at 154,

91 S.Ct. 1357 (citation and internal quotations omitted); see also

Gonzales v. Raich, 545 U.S. 1, 23, 125 S.Ct. 2195, 162 L.Ed.2d 1

(2005).

In two other cases decided more than fifty years after

Wickard, the Court examined the outer bounds of Congress’s power

under the third strand of the Commerce Clause by focusing on

whether the activity being regulated was “economic” in nature. In

Lopez, the plaintiff challenged the Gun-Free School Zones Act of

1990, 18 U.S.C. § 922(q)(1)(A) (1988 ed., Supp. V), which

criminalized the possession of a firearm in a school zone. The

Court held that Congress had exceeded its authority in enacting the

law because possession of a firearm “ha[d] nothing to do with

‘commerce’ or any sort of economic enterprise”; because the law

itself was “not an essential part of a larger regulation of

economic activity, in which the regulatory scheme could be undercut

unless the intrastate activity were regulated”; and because the law

contained no jurisdictional element to ensure it would affect only

interstate, and not intrastate, commerce. 514 U.S. at 561, 115

S.Ct. 1624.

The Court also noted the lack of any congressional findings

showing that handgun violence substantially affects interstate

commerce. Finally, the Court refused to “pile inference upon

-31-
inference” to connect handgun violence with interstate commerce

because it concluded that upholding a law on the basis of such a

logical stretch would erode the constitutional limits on Congress’s

power. Id. at 563-65, 115 S.Ct. 1624.

Ten years later, in Morrison, the Court reinforced Lopez’s

emphasis on the “economic” nature of the activity allegedly

affecting interstate commerce when it struck down a section of the

1994 Violence Against Women Act (“VAWA”), 42 U.S.C. § 40302, which

provided a federal civil cause of action for victims of gender-

motivated violence. United States v. Morrison, 529 U.S. 598, 120

S.Ct. 1740, 146 L.Ed.2d 658 (2000). Reviewing its decision in

Lopez, the Court concluded that “the noneconomic, criminal nature

of the conduct at issue was central to our decision in that case.”

Id. at 610, 120 S.Ct. 1740. The Court further stated that “[w]hile

we need not adopt a categorical rule against aggregating the

effects of any noneconomic activity in order to decide these cases,

thus far in our Nation’s history our cases have upheld Commerce

Clause regulation of intrastate activity only where that activity

is economic in nature.” Id. at 613, 120 S.Ct. 1740.

Because VAWA regulated activity--gender-motivated crimes of

violence--that was not economic in nature, and because the statute

did not include a jurisdictional element, the Morrison Court

concluded that the law did not fall within Congress’s Commerce

-32-
Clause power. Although Congress did include in VAWA some findings

on the impact of gender-motivated violence on the economy, the

Court did not regard them as dispositive. Instead, the Court

considered the link which Congress found between gender-motivated

violence and interstate commerce to be too attenuated, and feared

that upholding the law on such a basis could lead Congress to “use

the Commerce Clause to completely obliterate the Constitution’s

distinction between national and local authority . . . .” Id. at

615, 120 S.Ct. 1740.

Lopez and Morrison establish additional principles which must

guide this Court’s analysis. Most importantly, Lopez and Morrison

make clear that Congress may not rely on its Commerce Clause power

to regulate purely non-economic activities when the effect on

interstate commerce is shown only by “pil[ing] inference upon

inference.” Lopez, 514 U.S. at 563-65, 115 S.Ct. 1624.

Significantly, however, Lopez stated that a regulation may be

upheld if it is “an essential part of a larger regulation of

economic activity, in which the regulatory scheme could be undercut

unless the intrastate activity were regulated.” Id. at 561, 115

S.Ct. 1624.

Morrison also made clear that courts undertaking

constitutional review must determine whether Congress had a

rational basis that is not overly attenuated for concluding that

-33-
the class of activity substantially affects interstate commerce.

See Gonzales, 545 U.S. at 22, 125 S.Ct. 2195. In doing so,

congressional findings regarding the regulated activity’s impact on

interstate commerce must be considered, although they are not

necessarily dispositive. Morrison, 529 U.S. at 614-15, 120 S.Ct.

1740.

Finally, the most recent Commerce Clause case of significance

to this lawsuit, Gonzales v. Raich, reaffirmed the continuing

vitality of Wickard. Gonzales, 545 U.S. 1, 125 S.Ct. 2195. In

Gonzales, two plaintiffs who were producing and consuming marijuana

for their own medical treatment pursuant to California law

challenged the Controlled Substances Act (“CSA”), a federal

regulatory scheme which prohibits the intrastate manufacture and

possession of marijuana. The Court upheld the CSA, noting the

striking similarity of the facts in Gonzales to those in Wickard.

In Gonzales, the Court emphasized that the “case law firmly

establishes Congress’ power to regulate purely local activities

that are part of an economic ‘class of activities’ that have a

substantial effect on interstate commerce.” Id. at 17, 125 S.Ct.

2195. The Court therefore distinguished Gonzales from Lopez and

Morrison on the basis that the production and consumption of

marijuana for medical treatment was a “quintessentially economic”

-34-
activity, unlike the possession of a firearm or gender-motivated

violence. Id. at 25, 125 S.Ct. 2195.

The Court also rejected the argument that, although the larger

regulatory scheme contained in the CSA was constitutional, its

particular application to the California plaintiffs’ intrastate,

non-commercial activities was not:

We have never required Congress to legislate
with scientific exactitude. When Congress
decides that the total incidence of a practice
poses a threat to a national market, it may
regulate the entire class.

Id. at 17-18, 125 S.Ct. 2195. In sum, the Court held that Congress

may regulate an entire class of activities if, in the aggregate,

that class has a substantial effect on interstate commerce, even if

particular instances of the activity do not. Id.

When considered together, as they must be, Wickard, Lopez,

Morrison, and Gonzales establish three major lines of inquiry. See

id. at 15, 125 S.Ct. 2195 (“[N]one of [the] Commerce Clause cases

can be viewed in isolation.”). First, the Court must consider

whether the decision not to purchase health insurance is an

“economic” one, like the activities in Wickard and Gonzales, or a

“non-economic” one like those in Lopez and Morrison. Second, if the

decision is economic, the Court must determine whether Congress had

a rational basis for concluding that such decisions, when taken in

the aggregate, substantially affect the national health care

-35-
market. Third, the activity may be found to be within the reach of

Congress’s Commerce Clause power if it is “an essential part of a

larger regulation of economic activity, in which the regulatory

scheme could be undercut unless the intrastate activity were

regulated.” Lopez, 514 U.S. at 561, 115 S.Ct. 1624.

b. Application of Long-Standing Principles of
Commerce Clause Jurisprudence to Plaintiffs’
Claim

With these principles in mind, the Court now turns to its

analysis of Defendants’ 12(b)(6) Motion. In undertaking this

analysis, the Court is mindful of the proper balance of power among

the different branches of the federal government and, in

particular, of its duty to apply a presumption of constitutionality

when reviewing laws passed by Congress. See Morrison, 529 U.S. at

606, 120 S.Ct. 1740 (“Due respect for the decisions of a coordinate

branch of Government demands that we invalidate a congressional

enactment only upon a plain showing that Congress has exceeded its

constitutional bounds.”). At the same time, this Court must also be

mindful of the Supreme Court’s consistent warning that the outer

limits of the Commerce Clause must be respected, lest “the

distinction between what is national and what is local” be

“obliterate[d],” resulting in “a completely centralized

government.” Jones & Laughlin Steel, 301 U.S. at 37, 57 S.Ct. 615.

-36-
 When it enacted § 1501 of the Affordable Care Act, Congress

made several findings, chief among them the general finding that

“[t]he individual responsibility requirement provided for in this

section . . . is commercial and economic in nature, and

substantially affects interstate commerce.” ACA § 1501(a)(1). Thus,

there can be no doubt that it was the intent of Congress to invoke

its Commerce Clause power in enacting § 1501.9

Congress’s authority under the Commerce Clause to regulate the

interstate insurance markets has long been established. United

States v. South-Eastern Underwriters Ass’n, 322 U.S. 533, 552-53,

64 S.Ct. 1162, 88 L.Ed. 1440 (1944). In addition, there is nothing

extraordinary about Congress’s use of its Commerce Clause power to

rein in the price of health insurance policies. “It is well

established by decisions of this Court that the power to regulate

commerce includes the power to regulate the prices at which

commodities in that commerce are dealt in and practices affecting

such prices.” Wickard, 317 U.S. at 128, 63 S.Ct. 82. The question

before this Court, then, is whether Congress’s conclusion that §

9
While such congressional findings are not dispositive of
this Court’s inquiry into the constitutionality of § 1501, they can
help to clarify the purpose of the statutory scheme. See Gonzales,
545 U.S. at 21, 125 S.Ct. 2195 (“[C]ongressional findings are
certainly helpful in reviewing the substance of a congressional
statutory scheme, particularly when the connection to commerce is
not self-evident, and [] we will consider congressional findings in
our analysis when they are available.”).

-37-
1501 was within the reach of its Commerce Clause powers is in

accord with the principles which have been well established in the

Commerce Clause cases discussed above.

(1) An Individual’s Decision to Purchase or
Not to Purchase Health Insurance Is an
“Economic” One

The first question which must be answered is whether

Plaintiffs’ decisions not to purchase health insurance are

“economic” in nature. As noted above, Congress has clear authority

under the Commerce Clause to regulate the insurance markets because

insurance policies are “commodities” in the flow of interstate

commerce. South-Eastern Underwriters Ass’n, 322 U.S. at 552-53,

546-47, 64 S.Ct. 1162. Both the decision to purchase health

insurance and its flip side--the decision not to purchase health

insurance--therefore relate to the consumption of a commodity: a

health insurance policy.

It therefore follows that both decisions, whether positive or

negative, are clearly economic ones. See Gonzales, 545 U.S. at 25-

26, 125 S.Ct. 2195 (“‘Economics’ refers to ‘the production,

distribution, and consumption of commodities.’”) (quoting Webster’s

Third New International Dictionary 720 (1966)). Thus, unlike Lopez

and Morrison, which involved non-economic activity such as the

possession of a firearm or gender-motivated violence, this case

-38-
involves an economic activity: deciding whether or not to purchase

health insurance.

(2) In the Aggregate, the Decisions of
Individuals to Forgo Health Insurance
Substantially Affect the National Health
Care Market

Next, the Court must determine whether Congress had a rational

basis for concluding that such decisions, when considered in the

aggregate, substantially affect the national health insurance

market. The findings on this subject could not be clearer: the

great majority of the millions of Americans who remain uninsured

consume medical services they cannot pay for, often resulting in

personal bankruptcy. In fact, the ACA’s findings state that “62% of

all personal bankruptcies are caused in part by medical expenses.”

ACA § 1501(a)(2)(G), as amended by § 10106. Of even greater

significance to the national economy is the fact that these

uninsured individuals are, in fact, shifting the uncompensated

costs of those services--which totaled $43 billion in 2008--onto

other health care market participants, as well as federal and state

governments and American taxpayers. See ACA §§ 1501(a)(2)(F), (G),

as amended by § 10106; Thomas More Law Ctr., 720 F.Supp.2d at 894.

Because of this cost-shifting effect, the individual decision

to forgo health insurance, when considered in the aggregate, leads

to substantially higher insurance premiums for those other

individuals who do obtain coverage. According to Congress, the

-39-
uncompensated costs of caring for the uninsured are passed on by

health care providers to private insurers, which in turn pass on

the cost to purchasers of health insurance. “This costshifting

increases family premiums by on average over $1,000 a year.” ACA §

1501(a)(2)(F), as amended by § 10106. Thus, the aggregate effect on

interstate commerce of the decisions of individuals to forgo

insurance is very substantial.10

Further, the effect on insurance premiums is not at all

attenuated, as were the links between the regulated activities and

interstate commerce in Lopez and Morrison. In this case, the link

is strikingly similar to that described in Wickard: individuals are

actively choosing to remain outside of a market for a particular

commodity, and, as a result, Congress’s efforts to stabilize prices

for that commodity are thwarted. As Wickard demonstrates, the

effects of such market-distorting behavior are sufficiently related

to interstate commerce to justify Congress’s efforts to stabilize

the price of a commodity through its Commerce Clause power.

10
To put it less analytically, and less charitably, those
who choose--and Plaintiffs have made such a deliberate choice--not
to purchase health insurance will benefit greatly when they become
ill, as they surely will, from the free health care which must be
provided by emergency rooms and hospitals to the sick and dying who
show up on their doorstep. In short, those who choose not to
purchase health insurance will ultimately get a “free ride” on the
backs of those Americans who have made responsible choices to
provide for the illness we all must face at some point in our
lives.

-40-
 For the foregoing reasons, the Court finds that Congress had

a rational basis for its conclusion that the aggregate of

individual decisions not to purchase health insurance substantially

affects the national health insurance market. Consequently,

Congress was acting within the bounds of its Commerce Clause power

when it enacted § 1501 in order, as Chief Justice Marshall said,

“to prescribe the rule by which [interstate] commerce is to be

governed.” Gibbons, 9 Wheat. at 196, 6 L.Ed. 23. Thus, Defendants’

Motion to Dismiss on the basis that Plaintiffs have failed to state

a constitutional claim is granted.

(3) Necessary and Proper Clause

The Necessary and Proper Clause delegates to Congress the

power “[t]o make all Laws which shall be necessary and proper for

carrying into Execution the foregoing Powers, and all other Powers

vested by this Constitution in the Government of the United States,

or in any Department or Officer thereof.” U.S. Const., art. I § 8.

This clause is best understood as “a caveat that the Congress

possesses all the means necessary to carry out the specifically

granted ‘foregoing’ powers of § 8 ‘and all other Powers vested by

this Constitution,’” Kinsella v. United States ex rel. Singleton,

361 U.S. 234, 247, 80 S.Ct. 297, 4 L.Ed.2d 268 (1960) (quoting U.S.

Const., art. I § 8), rather than as an independent source of

congressional power.

-41-
 As the Supreme Court recently noted, the Necessary and Proper

Clause “grants Congress broad authority to enact federal

legislation.” United States v. Comstock, 130 S.Ct. 1949, 1956, 176

L.Ed.2d 878 (2010). “Let the end be legitimate, let it be within

the scope of the constitution, and all means which are appropriate,

which are plainly adapted to that end, which are not prohibited,

but consist with the letter and spirit of the constitution, are

constitutional.” McCulloch v. Maryland, 4 Wheat. 316, 421, 4 L.Ed.

579 (1819). Courts look to see whether the challenged statute

constitutes a means that is “rationally related to the

implementation of a constitutionally enumerated power” when

determining whether it falls within Congress’s power under the

Necessary and Proper Clause. Comstock, 130 S.Ct. at 1956. In the

specific context of the Commerce Clause, the Supreme Court held in

Lopez that regulation of intrastate economic activity may be upheld

if it is found to constitute “an essential part of a larger

regulation of economic activity, in which the regulatory scheme

could be undercut unless the intrastate activity were regulated.”

Lopez, 514 U.S. at 561, 115 S.Ct. 1624.

As noted above, the individual mandate is best viewed not as

a stand-alone reform, but as an essential element of the larger

regulatory scheme contained in the ACA. For example, without the

individual mandate, § 1001 of the ACA, which prohibits insurance

-42-
companies from denying or limiting coverage on the basis of pre-

existing conditions, would otherwise create incentives for people

to wait until they are sick or injured to obtain insurance. Not

only might this increase the incidence of sickness by discouraging

such individuals from obtaining preventive care, but insurance

premiums would rise for all other individuals as a result. See

Thomas More Law Ctr., 720 F.Supp.2d at 895 (“As a result, the most

costly individuals [the sick] would be in the insurance system and

the least costly [the well] would be outside it. . . .

aggravat[ing] current problems with cost-shifting and lead[ing] to

even higher premiums.”). Thus, without § 1501’s individual mandate,

the ACA’s efforts to end discrimination in insurance on the basis

of pre-existing conditions would be financially untenable.

For this reason, the individual mandate provision is an

appropriate means which is rationally related to the achievement of

Congress’s larger goal of reforming the national health insurance

system. In other words, § 1501 is a clear-cut example of “an

essential part of a larger regulation of economic activity, in

which the regulatory scheme could be undercut unless the intrastate

activity were regulated.” Lopez, 514 U.S. at 561, 115 S.Ct. 1624.

Thus, the Court reaffirms its conclusion that Congress acted within

the bounds of its Commerce Clause power, especially when

-43-
considering the Necessary and Proper Clause, when it enacted §

1501.

As this analysis makes clear, the principles established by

the Supreme Court in its Commerce Clause jurisprudence, which of

course must guide this Court’s analysis, compel the conclusion that

§ 1501 was enacted pursuant to Congress’s Commerce Clause power.

Defendants’ Motion to Dismiss for failure to state a claim on the

basis that the Commerce Clause, when considered together with the

Necessary and Proper Clause, delegates to Congress the power to

enact § 1501’s individual mandate is therefore granted.

(4) Plaintiffs’ Arguments Attempting to
Distinguish this Case from Wickard and
Gonzales Are Unpersuasive

Despite the clear application of long-established Commerce

Clause principles to this case, Plaintiffs attempt to distinguish

it from Wickard and Gonzales in two ways. Specifically, Plaintiffs

argue (1) that § 1501 is not a valid exercise of the Commerce

Clause power because it reaches economic decision-making, which is

“passive activity” not subject to regulation under the Commerce

Clause case law, and (2) that, in any event, Congress cannot

regulate the entire class of individuals included under § 1501

because some, including Plaintiffs, will either continue to pay out

of pocket for medical services, rather than shift those costs onto

others, or will refuse medical care altogether.

-44-
 (a) Economic Decision-Making Is an
Activity Subject to Congress’s
Commerce Clause Power

First, Plaintiffs define the conduct regulated by § 1501 as

“being lawfully present in the United States without health

insurance,” which they contend is not activity at all, but rather

“abstract economic decision-making.” Pls.’ Opp’n at 17. The core of

Plaintiffs’ challenge is that Congress may not, under the auspices

of its Commerce Clause power, regulate such economic inactivity.

See id. at 12-13.

As previous Commerce Clause cases have all involved physical

activity, as opposed to mental activity, i.e. decision-making,

there is little judicial guidance on whether the latter falls

within Congress’s power. See Thomas More Law Ctr., 720 F.Supp.2d at

893 (describing the “activity/inactivity distinction” as an issue

of first impression). However, this Court finds the distinction,

which Plaintiffs rely on heavily, to be of little significance. It

is pure semantics to argue that an individual who makes a choice to

forgo health insurance is not “acting,” especially given the

serious economic and health-related consequences to every

individual of that choice. Making a choice is an affirmative

action, whether one decides to do something or not do something.

They are two sides of the same coin. To pretend otherwise is to

ignore reality.

-45-
 More importantly, the premise underlying Plaintiffs’

activity/inactivity distinction--that individuals can, in the

absence of § 1501’s individual mandate, remain outside of the

health care market altogether--is erroneous.

First, this Court agrees with the two other district courts

which have ruled that the individuals subject to § 1501’s mandate

provision are either present or future participants in the national

health care market. See Liberty Univ., 2010 WL 4860299, at *15

(“Nearly everyone will require health care services at some point

in their lifetimes, and it is not always possible to predict when

one will be afflicted by illness or injury and require care.”);

Thomas More Law Ctr., 720 F.Supp.2d at 894 (“The health care market

is unlike other markets. No one can guarantee his or her health, or

ensure that he or she will never participate in the health care

market. . . . The plaintiffs have not opted out of the health care

services market because, as living, breathing beings . . . they

cannot opt out of this market.”). Thus, the vast majority of

individuals, if not all individuals, will require some medical care

in their lifetime.

Second, in contrast to other markets for goods and services,

if an individual is sick or injured, medical providers may not

refuse basic medical services under federal law, regardless of the

-46-
individual’s ability to pay.11 See Emergency Medical Treatment and

Active Labor Act of 1986, 42 U.S.C. § 1395dd (requiring all

hospitals participating in Medicare and offering emergency services

to stabilize any patient who arrives, regardless of whether the

patient has insurance). In addition to this federal requirement,

most hospitals “have some obligation to provide care for free or

for a minimal charge to members of their community who could not

afford it otherwise” and “[f]or-profit hospitals also provide such

charity or reduced-price care.” Cong. Budget Office, Key Issues in

Analyzing Major Health Insurance Proposals 13 (2008).

11
This second aspect of the health care market
distinguishes the ACA from Plaintiffs’ hypothetical scenario in
which Congress enacts a law requiring individuals to purchase
automobiles in an attempt to regulate the transportation market.
Even assuming that all individuals require transportation in the
same sense that all individuals require medical services,
automobile manufacturers are not required by law to give cars to
people who show up at their door in need of transportation but
without the money to pay for it. Similarly, food and lodging are
basic necessities, but the Court is not aware of any law requiring
restaurants or hotels to provide either free of charge.
It should be emphasized that this distinction is not merely a
useful limiting principle on Congress’s Commerce Clause power.
Rather, it is a basic, relevant fact about the operation of the
health care market which is critical to understanding the ACA’s
efforts to reform the health care system. The requirement placed
upon medical providers by federal law to care for the sick and
injured without recompense is part of the cost-shifting problem
that Congress sought to redress by enacting the ACA. When a
supplier is obligated by law to produce goods or services for free,
there is bound to be a substantial effect on market prices if
consumers’ behavior results in that obligation’s frequent
invocation.

-47-
 The combined effect of these two unique aspects of the health

care market--the inevitability of individuals’ entrance into that

market and the obligation of providers to serve those who do enter-

-is to guarantee that nearly all individuals, rich or poor, are or

will be consumers of medical services. This effect distinguishes

the present case from Plaintiffs’ hypothetical scenario in which

Congress “could not have dealt with the issue of low wheat prices

[in Wickard] by declaring that all Americans must buy a specific

amount of wheat or pay a penalty for failing to do so.” Pls.’ Opp’n

at 13. Plaintiffs’ argument that the Commerce Clause power does not

extend to regulations which require individuals to enter a market

they would otherwise choose to remain outside of is irrelevant to

this case. Here, Congress enacted § 1501 based on its understanding

that (1) all individuals inevitably consume medical services and

(2) when they do consume those services, the way in which they pay

for them substantially affects market prices.

Thus, as inevitable participants in the health care market,

individuals cannot be considered “inactive” or “passive” in

choosing to forgo health insurance. Instead, as Defendants argue,

such a choice is not simply a decision whether to consume a

particular good or service, but ultimately a decision as to how

health care services are to be paid and who pays for them. See ACA

§ 1501(a)(2)(A), as amended by § 10106 (“The requirement [of

-48-
minimum essential coverage] 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 choosing not to purchase health insurance,

Plaintiffs are actively arranging their circumstances (whether to

save for their children’s education or buy a new car) so that they

must, in the future, rely on either their own resources or on

federal law requiring medical providers to care for the sick and

injured. There is no question, as Congress noted, that such

mandatory care often goes uncompensated, although ultimately paid

for by other market participants and the taxpayer. See ACA §

1501(a)(2)(F), as amended by § 10106. For these reasons, the Court

concludes that a decision not to purchase health insurance is an

“activity.”

(b) Congress May Regulate the Class of
Individuals Who Forgo Health
Insurance

Next, the Court turns to Plaintiffs’ argument that § 1501 is

unconstitutional because it reaches individuals who will either pay

for future medical services out of pocket or who will refuse

medical services altogether.

As stated above, Plaintiffs Ruffo and Rodriguez admit that

they will consume medical services in the future, but allege that

they will pay for all services out of pocket as they have in the

-49-
past. As an initial matter, the Court notes that Plaintiffs have no

way of predicting what their future medical costs will be. In 2008,

the average hospital stay in the United States lasted 4.6 days and

included total charges of $29,046. See U.S. Dep’t of Health and

Human Servs., Agency for Healthcare Research and Quality,

Healthcare Cost and Utilization Project (HCUP), available at

http://www.ahrq.gov/data/hcup/. If Plaintiffs Ruffo and Rodriguez

or dependents in their care were to become seriously ill,

necessitating hospital stays in excess of 4.6 days, one can only be

skeptical about how long they would be able to continue to pay out

of pocket for such costly medical services. Such skepticism seems

especially warranted in light of Plaintiffs’ admissions that their

concern about their ability to make the far less costly shared

responsibility payments in 2014 is already leading them to adjust

their current finances. Am. Compl. ¶¶ 60-62, 73. In fact, over 62%

of personal bankruptcies in this country are attributable in part

to medical expenses, a fact which Congress relied upon in enacting

§ 1501. See ACA § 1501(2)(G), as amended by § 10106.

In any event, even assuming that Plaintiffs will be able to

pay for their future medical expenses, the question is whether

Congress has the power to regulate the class of individuals

participating in the health care market, which includes Ruffo and

Rodriguez because they concede they will use health care services

-50-
in the future. This Court has already concluded that Congress’s

regulation of that class is within the limits of the Commerce

Clause power. Thus, § 1501 is constitutional regardless of whether

Plaintiffs Ruffo and Rodriguez, by paying out-of-pocket for every

medical charge accrued, will individually avoid the cost-shifting

effect which § 1501 is meant to ameliorate. See Gonzales, 545 U.S.

at 17-22, 125 S.Ct. 2195 (refusing to “excise individual components

of th[e] larger scheme”); Perez, 402 U.S. at 154-55, 91 S.Ct. 1357

(“Where the class of activities is regulated and that class is

within the reach of federal power, the courts have no power to

excise, as trivial, individual instances of the class.”) (internal

quotations and citation omitted).

In contrast to Plaintiffs Ruffo and Rodriguez, Plaintiffs Lee

and Seven-Sky12 allege that they will remain passive, meaning they

will not enter the national health care market in the future to

consume services no matter what their circumstances are. Similar

avowals that “non-commercial” activity would remain as such were

viewed with some skepticism in both Wickard and Gonzales. See

Wickard, 317 U.S. at 128, 63 S.Ct. 82 (stating that home-consumed

wheat could have a substantial influence on price and market

conditions because “being in marketable condition such wheat

12
It should be remembered that Plaintiff Mead, who made the
same allegation, was dismissed for lack of standing. See supra Part
III.A.1.

-51-
overhangs the market and if induced by rising prices tends to flow

into the market and check price increases”); Gonzales, 545 U.S. at

31-32, 125 S.Ct. 2195 (“[T]he danger that excesses [of marijuana

produced for personal consumption] will satisfy some of the

admittedly enormous demand for recreational use seems obvious.”).

It is worth noting that, like the farmer and marijuana user in

Wickard and Gonzales, respectively, individuals like Plaintiffs who

allege now that they will refuse medical services in the future may

well find their way into the health care market when they face the

reality of illness or injury.

Indeed, for the reasons discussed above, this Court has

rejected the premise that individuals can opt out of the health

care market indefinitely. See supra Part III.B.1.b(4)(a). The Court

therefore likewise rejects Plaintiffs’ argument that Congress

cannot subject them to regulation under § 1501 because they will

never consume medical services.13

13
It is correct that, for the purposes of deciding a Rule
12(b)(6) motion, this Court must accept the factual allegations in
Plaintiffs’ Amended Complaint as true. Iqbal, 129 S.Ct. at 1949-50.
However, Plaintiffs’ allegations as to their future conduct are
purely speculative and therefore unprovable. As such, they are not
entitled to an assumption of truth. See Sprewell v. Golden State
Warriors, 266 F.3d 979, 988 (9th Cir. 2001) (explaining that a
court reviewing a 12(b)(6) motion is not required “to accept as
true allegations that are merely conclusory, unwarranted deductions
of fact, or unreasonable inferences”).

-52-
 Even assuming for the purposes of this Motion, however, that

Plaintiffs Lee and Seven-Sky do remain committed to refusing

medical care throughout their lives, Congress may still regulate

the larger class of individuals when it “decides that the total

incidence of a practice poses a threat to a national market.”

Gonzales, 545 U.S. at 17, 125 S.Ct. 2195. Consequently, the Court

looks not to Plaintiffs’ particular situation, but must ask instead

whether the practice of the broader class of uninsured individuals

threatens the national health care market. However, “when it is

necessary in order to prevent an evil to make the law embrace more

than the precise thing to be prevented it may do so.’” Perez, 402

U.S. at 154-55, 91 S.Ct. 1357 (quoting Westfall v. United States,

274 U.S. 256, 259, 47 S.Ct. 629, 71 L.Ed. 1036 (1927)). Because

this Court has determined that the practices of the broader class

of uninsured individuals substantially affects the health care

market, Plaintiffs’ own individual activity may be regulated

pursuant to Congress’s Commerce Clause power.

In addition, as this Court has explained, § 1501’s individual

mandate is “an essential part of a larger regulation of economic

activity, in which the regulatory scheme could be undercut unless

the intrastate activity were regulated.” Lopez, 514 U.S. at 561,

115 S.Ct. 1624. Because excepting individuals like Plaintiffs from

§ 1501 would create a “gaping hole” in the ACA, this Court declines

-53-
to do so. Gonzales, 545 U.S. at 22, 125 S.Ct. 2195 (refusing to

excise individual components involving only intrastate activity

from Congress’s larger regulatory scheme in part because exclusion

of such components would leave a “gaping hole” in the CSA).

For all these reasons, the Court finds Plaintiffs’ arguments

against dismissal of their constitutional claim unpersuasive. The

crux of Plaintiffs’ arguments is that § 1501 is an unprecedented

attempt by Congress to regulate individual behavior, and therefore

threatens individuals’ freedom of choice. Appealing as this

emotionally charged argument may sound, the ACA is not as

unprecedented as Plaintiffs claim: as already discussed, Congress’s

broad power to regulate individual behavior under the Commerce

Clause is well established. See Gibbons, 9 Wheat. at 196, 6 L.Ed.

23; Wickard, 317 U.S. at 118-29, 63 S.Ct. 82; Gonzales, 545 U.S. at

15-33, 125 S.Ct. 2195.

In addition, the mere fact that a case presents a novel set of

facts is not cause for viewing an act of Congress with skepticism

or doubt. See, e.g., Liberty Univ., 2010 WL 4860299, at *14 (“While

the unique nature of the market for health care and the breadth of

the Act present a novel set of facts for consideration, the

well-settled principles expounded in [Gonzales] and Wickard control

the disposition of this claim.”); Florida ex rel. McCollum, 715

F.Supp.2d at 1164 (“[T]o say that something is “novel” and

-54-
“unprecedented” does not necessarily mean that it is

“unconstitutional” and “improper.”). On the contrary, as noted

above, this Court is bound to grant congressional action a

presumption of constitutionality. Morrison, 529 U.S. at 606, 120

S.Ct. 1740 .

Finally, Plaintiffs argue that upholding § 1501 under the

Commerce Clause will eviscerate any limits on Congress’s power.

First, this Court emphasizes that its task is only to determine

whether this particular statute is constitutional, and not to

speculate about other Commerce Clause challenges presenting

different factual scenarios which may arise in the future. Second,

there is a straightforward response to the “parade of horribles”

claim: the limits on Congress’s Commerce Clause power are spelled

out clearly in Lopez, 514 U.S. 549, 115 S.Ct. 1624, and Morrison,

529 U.S. 598, 120 S.Ct. 1740. These two cases establish that (1)

the activity subject to regulation under the Commerce Clause must

be economic in nature, (2) the link between the activity and

interstate commerce must not be too attenuated, and (3) other

activities may be upheld if they are an essential part of a larger

regulatory scheme. Because § 1501 satisfies these requirements,

this Court sees no danger of granting Congress limitless power by

concluding that § 1501 was enacted pursuant to the Commerce Clause.

-55-
 2. General Welfare Clause

As an alternative to their Commerce Clause arguments,

Defendants argue that the General Welfare Clause, also called the

Taxing and Spending Clause, in Article I, Section 8 of the

Constitution grants Congress the power to enact the shared

responsibility payment provision, 26 U.S.C. § 5000A(b). The General

Welfare Clause states that “[t]he Congress shall have Power To lay

and collect Taxes, Duties, Imposts and Excises, to pay the Debts

and provide for the common Defence and general Welfare of the

United States; but all Duties, Imposts and Excises shall be uniform

throughout the United States.” U.S. Const. art. I, § 8. Under this

Clause, Congress must have intended 26 U.S.C. § 5000A(b) as a tax

if it is to be deemed constitutional.

Therefore, we must first consider whether § 5000A(b), which

uses the term “penalty,” operates as a tax. See Helwig v. United

States, 188 U.S. 605, 613, 23 S.Ct. 427, 47 L.Ed. 614 (1903).

(“[I]n the absence of any declaration by Congress affecting the

manner in which the provision shall be treated, courts must decide

the matter in accordance with their views of the nature of the

act.”). In reaching its decision, the Court notes that, to date,

every court which has considered whether § 1501 operates as a tax

has concluded that it does not. See Goudy-Bachman, 2011 WL 223010,

at *10-12; Liberty Univ., 2010 WL 4860299, at *9-11; State of

-56-
Florida, 716 F.Supp.2d at 1130-41; United States Citizens Ass’n,

2010 WL 4947043, at *5; Virginia ex rel. Cuccinelli v. Sebelius,

728 F.Supp.2d 768, 786-88 (E.D. Va. 2010).

“In construing a statute, the court begins with the plain

language of the statute.” United States v. Braxtonbrown-Smith, 278

F.3d 1348, 1352 (D.C. Cir. 2002). As already noted, Congress chose

to label the shared responsibility payment in § 5000A(b) as a

penalty, although it chose to label several other assessments

required under the ACA as taxes. Compare 26 U.S.C. § 5000A(b)

(labelling the shared responsibility payment a “penalty”) with ACA

§§ 1405, 9001, 9015, 10907 (imposing “taxes”).

Because “[w]e must strive to interpret a statute to give

meaning to every clause and word,” this choice of language

obviously suggests that Congress did not intend the mandatory

payment in § 5000A(b) to act as a revenue-raising tax, but rather

as a punitive measure. Donnelly v. FAA, 411 F.3d 267, 295 (D.C.

Cir. 2005); see also Dep’t of Revenue v. Kurth Ranch, 511 U.S. 767,

779-80, 114 S.Ct. 1937, 128 L.Ed.2d 767 (1994) (“Whereas fines,

penalties, and forfeitures are readily characterized as sanctions,

taxes are typically different because they are usually motivated by

revenue-raising, rather than punitive, purposes.”); Russello v.

United States, 464 U.S. 16, 23, 104 S.Ct. 296, 78 L.Ed.2d 17 (1983)

(“Where Congress includes particular language in one section of a

-57-
statute but omits it from another section of the same Act, it is

generally presumed that Congress acts intentionally and purposely

in the disparate inclusion or exclusion.”).

This conclusion is bolstered by the Congressional findings in

support of § 5000A. First, Congress makes clear that it is invoking

its regulatory authority under the Commerce Clause, not its power

to lay and collect taxes. See ACA § 1501(a), as amended by § 10106.

Second, the findings demonstrate that the goal of § 5000A is not to

raise revenue, but to achieve near-universal health care coverage

by giving individuals the incentive to maintain their health

insurance under threat of penalty:

[I]f there were no requirement [to maintain
minimum essential coverage], 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 preexisting
conditions can be sold.

Id. at § 1501(a)(2)(I), as amended by § 10106.

Finally, as Judge Vinson of the United States District Court

for the Northern District of Florida discusses in great detail, the

legislative history of § 1501 makes clear that Congress did not

-58-
intend the provision to operate as a tax. See State of Florida, 716

F.Supp.2d at 1130-41. To the contrary, the legislative history

indicates that Congress specifically rejected the term “tax” in

favor of “penalty.” Id. As Judge Vinson notes, “‘[f]ew principles

of statutory construction are more compelling than the proposition

that Congress does not intend sub silentio to enact statutory

language that it has earlier discarded in favor of other

language.’” Id. at 1134 (quoting INS v. Cardoza-Fonseca, 480 U.S.

421, 442, 107 S.Ct. 1207, 94 L.Ed.2d 434 (1987)).

For these reasons, the Court concludes that Congress did not

intend § 1501 to operate as a tax, and therefore Defendants cannot

rely on the General Welfare Clause as authority for its enactment.

Consequently, Defendants’ Motion to Dismiss on the basis that §

1501 was constitutionally enacted pursuant to the General Welfare

Clause is denied.

C. Religious Freedom Restoration Act

Finally, Defendants move under Rule 12(b)(6) for dismissal of

Plaintiffs Lee and Seven-Sky’s claim that § 1501 violates RFRA.

RFRA prevents the federal government from substantially burdening

a person’s exercise of religion, “even if the burden results from

a rule of general applicability.” 42 U.S.C. § 2000bb-1(a). The only

exception to this rule is when the burden “(1) is in furtherance of

a compelling governmental interest; and (2) is the least

-59-
restrictive means of furthering that compelling governmental

interest.” Id. § 2000bb-1(b); see also Gonzales v. O Centro

Espirita Beneficente Uniao do Vegetal, 546 U.S. 418, 424, 126 S.Ct.

1211, 163 L.Ed.2d 1017 (2006).

To survive Defendants’ Motion to Dismiss, the Amended

Complaint must allege sufficient facts showing that § 1501 imposes

a substantial burden on Plaintiffs’ exercise of religion. Under

RFRA, “religious exercise” includes “any exercise of religion,

whether or not compelled by, or central to, a system of religious

belief.” 42 U.S.C. §§ 2000bb-2(4), 2000cc-5(7). When considering a

RFRA claim, the focus is therefore not on the centrality of the

religious exercise to the adherent’s own religion, but on whether

the adherent’s sincere religious exercise is substantially

burdened. Kaemmerling v. Lappin, 553 F.3d 669, 678 (D.C. Cir. 2008)

(citing Levitan v. Ashcroft, 281 F.3d 1313, 1321 (D.C. Cir.2002)).

“A substantial burden exists when government action puts

‘substantial pressure on an adherent to modify his behavior and to

violate his beliefs, Thomas v. Review Bd., 450 U.S. 707, 718, 101

S.Ct. 1425, 67 L.Ed.2d 624 (1981) . . . . An inconsequential or de

minimis burden on religious practice does not rise to this level,

nor does a burden on activity unimportant to the adherent’s

religious scheme.” Id.

The Amended Complaint states that:

-60-
 [Lee and Seven-Sky] believe[] in trusting in
God to protect [them] from illness or injury,
and to heal [them] of any afflictions, no
matter the severity of the health issue, and
[they] do[] not need, or want to be forced to
buy, health insurance coverage . . . In
addition, [Lee and Seven-Sky have] a sincerely
held religious belief that God will provide
for [their] physical, spiritual, and financial
well-being. Being forced to buy health
insurance conflicts with [their] religious
faith because [they] believe[] that [they]
would be indicating that [they] need[] a
backup plan and [are] not really sure whether
God will, in fact, provide for [their] needs.
. . . Because [Lee and Seven-Sky] believe[] in
relying on God to preserve [their] health and
provide for [their] physical, spiritual, and
financial needs, and object[] to participation
in the health insurance system, the Act
imposes direct and substantial religious and
financial burdens upon [them] by requiring
[them] to either 1) purchase and maintain
minimum essential coverage, without any
consideration of [their] individual needs,
Christian faith, and financial situation, or
2) pay an annual shared responsibility
payment.

Am. Compl. ¶¶ 15-18, 28-33, 42-45. In essence, then, Plaintiffs

allege that § 1501‘s minimum essential coverage requirement

conflicts with their Christian faith because it requires them to

perform an act that implies that they doubt God’s ability to

provide for their health.

Accepting these allegations as true, the conflict alleged

between § 1501’s requirements and Plaintiffs’ Christian faith does

not rise to the level of a substantial burden. First, Plaintiffs

have failed to allege any facts demonstrating that this conflict is

-61-
more than a de minimus burden on their Christian faith. Second, it

is unclear how § 1501 puts substantial pressure on Plaintiffs to

modify their behavior and to violate their beliefs, as it permits

them to pay a shared responsibility payment in lieu of actually

obtaining health insurance. See 42 U.S.C. § 5000A(b). In fact,

Plaintiffs specifically allege in the Amended Complaint that they

view this shared responsibility payment as “the lesser of two

evils” and therefore intend to pay it rather than purchase health

insurance. Am. Compl. ¶¶ 19, 33, 46. Finally, as Defendants point

out, Plaintiffs routinely contribute to other forms of insurance,

such as Medicare, Social Security, and unemployment taxes, which

present the same conflict with their belief that God will provide

for their medical and financial needs. See Defs.’ Mot. at 37.

Even if § 1501 does substantially burden the exercise of

Plaintiffs’ Christian faith, Plaintiffs have failed to state a

claim for relief under RFRA because the individual mandate

provision serves a compelling public interest and is the least

restrictive means of furthering that interest. 42 U.S.C. § 2000bb-

1(b); see Kaemmerling, 553 F.3d at 680. First, the Government

clearly has a compelling interest in safeguarding the public health

by regulating the health care and insurance markets. See, e.g.,

Olsen v. Drug Enforcement Admin., 878 F.2d 1458, 1462 (D.C. Cir.

1989) (noting compelling interest in protecting individual health

-62-
and social welfare). RFRA requires that this compelling interest

apply specifically to the “particular claimant whose sincere

exercise of religion is being substantially burdened.” O Centro

Espirita, 546 U.S. at 430-31, 126 S.Ct. 1211. In this case,

Congress has made clear that the goal of § 1501 is to achieve near-

universal health insurance coverage. ACA § 1501(a)(2). Thus,

Congress’s compelling interest--reforming the health care market by

increasing coverage--applies to Plaintiffs, just as it applies to

all individuals.

Second, the individual mandate, as enacted in § 1501, is the

least restrictive means of furthering this compelling interest.

Congress found that, “[i]n 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.” ACA

§ 1501(a)(2)(A), as amended by § 10106. In addition, § 1501

includes a number of exemptions on the basis of religious

conscience, membership in a health care sharing ministry,

incarceration, poverty or inability to afford coverage, membership

in an Indian tribe, and hardship. 26 U.S.C. §§ 5000A(d), (e).

Finally, when pressed at oral argument to name a less restrictive

means of lowering health insurance premiums or otherwise improving

access to health care, Plaintiffs could not do so.

-63-
 Consequently, the Court concludes that (1) § 1501 does not

place a substantial burden on the exercise of Plaintiffs’ Christian

faith, and (2), even assuming that it does, it is the least

restrictive means of serving a compelling governmental interest.

Defendants’ Motion to Dismiss Plaintiffs’ RFRA claim is therefore

granted.

IV. CONCLUSION

For the reasons set forth above, Defendants’ Motion to Dismiss

is granted. An Order will accompany this Memorandum Opinion.

/s/
February 22, 2011 Gladys Kessler
United States District Judge

Copies to: attorneys on record via ECF

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