Vital Signs: Patterns: More People Praying About Health, Analysis Finds

More Americans are praying about their health, researchers have concluded.

Scientists analyzed data on 30,080 adults ages 18 and older who took part in the National Health Interview Survey in 2002 and on 22,306 adults who participated in 2007.

Forty-nine percent of adults said in 2007 that they had prayed about their health during the previous year, up from 43 percent in 2002. In 1999, only 14 percent of survey participants said they had prayed about their health.

Among those least likely to pray were people who exercised on a regular basis; researchers speculated they may not have had any health concerns. Those with higher incomes were also less likely to pray.

According to the analysis, published in the May issue of the journal Psychology of Religion and Spirituality, the use of prayer has increased in recent years among adults of all ages. Women, black people, older and married individuals and those whose health status had changed — for better or worse — were more likely than others to pray. People with episodes of depression and dental pain also turned to prayer at high rates.

“We were surprised,” said Amy Wachholtz, director of health psychology at University of Massachusetts and co-author of the paper. “Our best guess is that it has to do with 9/11, but that’s an untested hypothesis. There doesn’t seem to be any other primary, overwhelming issue that would have so globally affected people.”

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Nursing Homes Seek Exemptions From Health Law

The numbers are stark. Among workers who provide hands-on care to nursing home residents, one in four has no health insurance. Among those who provide care to people living at home, one in three is uninsured.

The new health care law is supposed to fix the problem by guaranteeing access to affordable coverage for all. But many nursing homes and home care agencies, alarmed at the cost of providing health insurance to hundreds of thousands of health care workers, have started a lobbying effort seeking some kind of exemption or special treatment.

Mark Parkinson, president of the American Health Care Association, the largest trade group for nursing homes, says the problem is that reimbursement rates for Medicaid and Medicare, set by government agencies, do not pay them enough to offer their employees medical coverage. “We do not have much ability to increase prices because we are so dependent on Medicaid and Medicare” for revenue, he said.

Mr. Parkinson acknowledged that when nursing homes do offer health insurance to employees, the benefits are often limited. The coverage “is probably not up to what will be required” by the federal law, he said.

Medicaid covers about two-thirds of nursing home residents. States set Medicaid rates, and many states, facing severe budget problems, have reduced payments for nursing homes.

Starting in 2014, the law will require employers with 50 or more full-time employees to offer affordable coverage or risk paying a penalty. For a midsize nursing home, that penalty could easily exceed $200,000 a year. Nursing home executives are urging Congress and the Obama administration to spare them from the penalties.

Vanessa Valerio, 25, a certified nursing assistant who earns $10 an hour at Lakeview Christian Home in Carlsbad, N.M., said she was uninsured because she could not afford the coverage offered by her employer.

The chief executive of the Lakeview nursing home, Joanna D. Knox, said the company used to pay the entire premium for employees. It now requires workers to pay $25 of the $585 monthly premium for individual coverage.

“When we started charging $25 a month,” Ms. Knox said, “many employees dropped coverage.” Of the home’s 200 employees, only 87 have elected it, she said, adding, “I don’t know how we could possibly absorb the additional cost of providing coverage for the other employees.”

Charlene A. Harrington, a professor at the School of Nursing at the University of California, San Francisco, said it would be a mistake for Congress or the administration to relieve nursing homes of the obligation to provide coverage to employees.

“It’s scandalous to have nursing home employees taking care of people when they themselves lack coverage and go without care,” Ms. Harrington said. “If employees have health insurance, they are more likely to be treated for illnesses, less likely to pass on infections to nursing home residents and more likely to get early treatment for occupational injuries.”

The rate of injuries in nursing homes is about twice the rate for all occupations, according to the Labor Department. Back injuries are common among those who lift patients and help them get in and out of bed.

Since the law was signed 14 months ago, the focus of lobbying has shifted. A tumultuous battle over the future of the health care system has given way to more concentrated efforts to undo or rewrite particular provisions.

Mr. Parkinson, a former Democratic governor of Kansas who is now the top Washington lobbyist for nursing homes, is pushing several ideas.

One option would give nursing homes more time to comply with the requirement to offer coverage. Another proposal, according to a list of options prepared by lobbyists for the industry, would waive or reduce the penalties for nursing homes “placed in financial distress as a result of the new mandates and fines.” Alternatively, Mr. Parkinson said, Congress could allow nursing homes to take tax deductions for the penalties, which under the 2010 law are nondeductible.

Health Insurers Making Record Profits as Many Postpone Care

 

The UnitedHealth Group, one of the largest commercial insurers, told analysts that so far this year, insured hospital stays actually decreased in some instances. In reporting its earnings last week, Cigna, another insurer, talked about the “low level” of medical use.

Yet the companies continue to press for higher premiums, even though their reserve coffers are flush with profits and shareholders have been rewarded with new dividends. Many defend proposed double-digit increases in the rates they charge, citing a need for protection against any sudden uptick in demand once people have more money to spend on their health, as well as the rising price of care.

Even with a halting economic recovery, doctors and others say many people are still extremely budget-conscious, signaling the possibility of a fundamental change in Americans’ appetite for health care.

“I am noticing my patients with insurance are more interested in costs,” said Dr. Jim King, a family practice physician in rural Tennessee. “Gas prices are going up, food prices are going up. They are deciding to put some of their health care off.” A patient might decide not to drive the 50 miles necessary to see a specialist because of the cost of gas, he said.

But Dr. King said patients were also being more thoughtful about their needs. Fewer are asking for an MRI as soon as they have a bad headache. “People are realizing that this is my money, even if I’m not writing a check,” he said.

For someone like Shannon Hardin of California, whose hours at a grocery store have been erratic, there is simply no spare cash to see the doctor when she isn’t feeling well or to get the $350 dental crowns she has been putting off since last year. Even with insurance, she said, “I can’t afford to use it.” Delaying care could keep utilization rates for insurers low through the rest of the year, according to Charles Boorady, an analyst for Credit Suisse. “The big question is whether it is going to stay weak or bounce back,” he said. “Nobody knows.”

Significant increases in how much people have to pay for their medical care may prevent a solid rebound. In recent years, many employers have sharply reduced benefits, while raising deductibles and co-payments so people have to reach deeper into their pockets.

In 2010, about 10 percent of people covered by their employer had a deductible of at least $2,000, according to the Kaiser Family Foundation, a nonprofit research group, compared with just 5 percent of covered workers in 2008.

Doctors, for one, say patients’ attitudes are changing. “Because it’s from Dollar 1 to Dollar 2,000, they are being really conscious of how they spend their money,” said Dr. James Applegate, a family physician in Grand Rapids, Mich. For example, patients question the need for annual blood work.

High deductibles also can be daunting. David Welch, a nurse in California whose policy has a $4,000 deductible, said he was surprised to realize he had delayed going to the dermatologist, even though he had a history of skin cancer. Mr. Welch, who has been a supporter of the need to overhaul insurance industry practices for the California Nurses Association union, said he hoped his medical training would help him determine when to go to the doctor. “I underestimated how much that cost would affect my behavior,” he said.

Dr. Rebecca Jaffe, a family practice doctor in Wilmington, Del., said more patients were asking for the generic alternatives to brand-name medicines, because of hefty co-payments. “Now, all of a sudden, they want the generic, when for years, they said they couldn’t take it,” she said.

The insurers, which base what they charge in premiums largely on what they expect to pay out in future claims, say they still expect higher demand for care later this year. “I think there’s a real concern about a bounce-back, a rebound, in utilization,” said Dr. Lonny Reisman, the chief medical officer for Aetna.

Because they say they expect costs to rebound, insurers have not been shy about asking for higher rates. In Oregon, for example, Regence BlueCross BlueShield, a nonprofit insurer that is the state’s largest, is asking for a 22 percent increase for policies sold to individuals. In California, regulators have been resisting requests from insurers to raise rates by double digits.

Some observers wonder if the insurers are simply raising premiums in advance of the full force of the health care law in 2014. The insurers’ recent prosperity — big insurance companies have reported first-quarter earnings that beat analysts expectations by an average of 30 percent — may make it difficult for anyone, politicians and industry executives alike, to argue that the industry has been hurt by the federal health care law. Insurers were able to raise premiums to cover the cost of the law’s early provisions, like insuring adult children up to age 26, and federal and state regulators have largely proved to be accommodating.

But 2014 and 2015 are likely to be far more challenging, as insurers are forced to adjust to the law’s greatest changes, like providing coverage to everyone regardless of whether they have an expensive pre-existing condition. “I think they’re going to go through a winter,” said Paul H. Keckley, executive director of the?Deloitte Center for Health Solutions, a research unit of the consulting firm Deloitte.

And while the slowing down of demand is good for insurers, at least in the short term, the concern is that patients may be tempted to skip important tests like colonoscopies or mammograms. The new health care law will eventually prevent most policies from charging patients for certain kinds of preventive care, but some plans still require someone to pay $500 toward a colonoscopy.

In recent times, insurers have prospered by pricing policies above costs, said Robert Laszewski, a former health insurance executive who is now a consultant in Alexandria, Va. The industry goes through underwriting cycles where the companies are better able to predict costs and make room for profits. “They’re benefiting from a very positive underwriting cycle,” he said.

“Maybe managed care is finally working,” he said. “Maybe this is the new normal.”

Still, he emphasized, health care costs, even if they are rising at 6 percent or 7 percent a year, are increasing at a much faster pace than overall inflation. “We haven’t solved the problem,” Mr. Laszewski said.

The Health Consumer: Speed Bumps on the Way to an A.D.H.D. Diagnosis

In school, she would procrastinate and then pull desperate all-nighters to study for an exam. She’d become hyperfocused on a project and let everything else fall by the wayside. Maintaining relationships was tricky. “I would concentrate intensely on a friend and then move on,” she said. She commuted to college one year simply because she had missed the deadline to apply for housing.

“I managed to achieve a lot, but it was difficult,” said Ms. Goldberg, a mother of three who lives near Philadelphia. “I sensed something was wrong, but others would always talk me out of it.”

Finally, in her late 40s, Ms. Goldberg was given a diagnosis of attention deficit hyperactivity disorder, a condition caused by signaling problems in the brain. The primary symptoms are impulsiveness, inattention, restlessness and poor self-regulation. Children with the condition tend to be hyperactive, but adults who have it often just seem distracted and disorganized.

Undiagnosed, A.D.H.D. can wreak havoc on relationships, finances and one’s self-esteem. Adults with the disorder are twice as likely as those without it to be divorced, for instance, and four times as likely to have car accidents. It’s no surprise that they also tend to have poor credit ratings.

“A.D.H.D. is a very debilitating mental disorder,” said Russell Barkley, a clinical professor of psychiatry at the Medical University of South Carolina. “It can produce more severe impairment, and in more domains of life, than depression or anxiety.”

More than 5 percent of adults have A.D.H.D., according to a recent study by Dr. Barkley. But just 10 percent of those adults have a formal diagnosis.

It’s an expensive problem for many consumers. Adults with the condition, particularly women, are frequently given a diagnosis of depression, anxiety or bipolar disorder instead — or their symptoms are dismissed, as Ms. Goldberg’s were.

Ms. Goldberg said of her eventual diagnosis: “It was so freeing. I realized, ‘I’m not stupid — I have a mental disorder.’?”

Just getting the correct diagnosis can be costly. “Many clinicians do not know how to spot the signs,” said Ari Tuckman, a psychologist in West Chester, Pa., and author of a book about A.D.H.D., “More Attention, Less Deficit” (Specialty Press, 2009).

Clinicians may arrive at the diagnosis with a snap judgment, or they may send patients for lengthy and expensive neuropsychological evaluations. Both approaches tend to miss the main symptoms — and therefore waste the patient’s time and money.

If you think that you may have A.D.H.D., or that a friend or family member may, the first thing to do is get a proper diagnosis. Here’s how to get tested and what to avoid.

Step 1: Test yourself.

Cost: Free.

If you’re not quite sure if you or a family member has the disorder, start by printing out the Adult A.D.H.D. Self-Report Scale and answering the 18-question assessment. It was developed by a team of psychiatrists in conjunction with the World Health Organization, and it is used by many clinicians to diagnose A.D.H.D.

The test is simple and has a straightforward scoring system. Use the results only as a guide to gauge your symptoms or a family member’s; it should not serve as a final diagnosis.

Bear in mind that A.D.H.D. is not something you suddenly develop as an adult; you are born with it. “If you tell me, ‘My life was fine until I was 24,’ you don’t have this disorder,” said Dr. Barkley.

Avoid: Snap diagnoses.

Diagnosing this disorder takes time. A quick assessment, even by your favorite doctor or therapist, can miss important signs.

“I can’t guess how many clients I have had who have seen other psychologists, psychiatrists and primary care physicians who missed their A.D.H.D., even though it was burning like a bonfire,” said Dr. Tuckman. “It’s possible to make a diagnosis by using a rating scale and a 10-minute discussion, but it’s also far too easy to make an inaccurate diagnosis or miss a diagnosis.”

Step 2: Find an experienced clinician.

Cost: $200 to $500.

Make an appointment, or more than one, with a psychiatrist, psychologist or neurologist who has expertise in diagnosing A.D.H.D. Ask your doctor or a psychotherapist for a recommendation, or contact a local chapter of the organization Children and Adults With Attention Deficit/Hyperactivity Disorder (informally known as Chadd) and inquire about local professionals.

Dr. Barkley also suggests calling a nearby medical school or university psychiatry program and asking whether there is a doctor on staff who specializes in adult A.D.H.D.

Nursing Homes Seek Exemptions From Health Law

The numbers are stark. Among workers who provide hands-on care to nursing home residents, one in four has no health insurance. Among those who provide care to people living at home, one in three is uninsured.

The new health care law is supposed to fix the problem by guaranteeing access to affordable coverage for all. But many nursing homes and home care agencies, alarmed at the cost of providing health insurance to hundreds of thousands of health care workers, have started a lobbying effort seeking some kind of exemption or special treatment.

Mark Parkinson, president of the American Health Care Association, the largest trade group for nursing homes, says the problem is that reimbursement rates for Medicaid and Medicare, set by government agencies, do not pay them enough to offer their employees medical coverage. “We do not have much ability to increase prices because we are so dependent on Medicaid and Medicare” for revenue, he said.

Mr. Parkinson acknowledged that when nursing homes do offer health insurance to employees, the benefits are often limited. The coverage “is probably not up to what will be required” by the federal law, he said.

Medicaid covers about two-thirds of nursing home residents. States set Medicaid rates, and many states, facing severe budget problems, have reduced payments for nursing homes.

Starting in 2014, the law will require employers with 50 or more full-time employees to offer affordable coverage or risk paying a penalty. For a midsize nursing home, that penalty could easily exceed $200,000 a year. Nursing home executives are urging Congress and the Obama administration to spare them from the penalties.

Vanessa Valerio, 25, a certified nursing assistant who earns $10 an hour at Lakeview Christian Home in Carlsbad, N.M., said she was uninsured because she could not afford the coverage offered by her employer.

The chief executive of the Lakeview nursing home, Joanna D. Knox, said the company used to pay the entire premium for employees. It now requires workers to pay $25 of the $585 monthly premium for individual coverage.

“When we started charging $25 a month,” Ms. Knox said, “many employees dropped coverage.” Of the home’s 200 employees, only 87 have elected it, she said, adding, “I don’t know how we could possibly absorb the additional cost of providing coverage for the other employees.”

Charlene A. Harrington, a professor at the School of Nursing at the University of California, San Francisco, said it would be a mistake for Congress or the administration to relieve nursing homes of the obligation to provide coverage to employees.

“It’s scandalous to have nursing home employees taking care of people when they themselves lack coverage and go without care,” Ms. Harrington said. “If employees have health insurance, they are more likely to be treated for illnesses, less likely to pass on infections to nursing home residents and more likely to get early treatment for occupational injuries.”

The rate of injuries in nursing homes is about twice the rate for all occupations, according to the Labor Department. Back injuries are common among those who lift patients and help them get in and out of bed.

Since the law was signed 14 months ago, the focus of lobbying has shifted. A tumultuous battle over the future of the health care system has given way to more concentrated efforts to undo or rewrite particular provisions.

Mr. Parkinson, a former Democratic governor of Kansas who is now the top Washington lobbyist for nursing homes, is pushing several ideas.

One option would give nursing homes more time to comply with the requirement to offer coverage. Another proposal, according to a list of options prepared by lobbyists for the industry, would waive or reduce the penalties for nursing homes “placed in financial distress as a result of the new mandates and fines.” Alternatively, Mr. Parkinson said, Congress could allow nursing homes to take tax deductions for the penalties, which under the 2010 law are nondeductible.

Appellate Court Hears Defense of Health Law

 

The 14 members of the United States Court of Appeals for the Fourth Circuit, the first appellate court to review the law, are evenly divided as appointees of Democratic and Republican presidents. That puts the odds of drawing three Democratic appointees in the computerized lottery at roughly 10 to 1. Lawyers do not learn the makeup of the panel until the day of the hearing.

The party of the appointing president is not necessarily predictive of a federal judge’s leanings. But in five decisions in lower courts, three Democratic-appointed judges have upheld the Affordable Care Act while two Republican-appointed judges have ruled that its central provision — the requirement that most Americans obtain health insurance — is unconstitutional.

At Tuesday’s hearing in Richmond, the three Fourth Circuit judges — Diana Gribbon Motz, who was appointed by President Bill Clinton, and the two Obama appointees, Andre M. Davis and James A. Wynn Jr. — challenged both sides with pointed questioning. The hearing lasted more than two hours.

As in the lower courts, the judges focused on the novel question of how to define the choice not to buy health insurance: as commercial activity that the Supreme Court has ruled can be regulated, or as inactivity that is beyond Congress’s reach.

They also devoted considerable time to discussing whether Virginia’s attorney general had legal standing to challenge the insurance mandate, because it would impose a requirement on individuals but not on states.

Virginia stakes its right to sue on its enactment of a state law aimed at exempting residents from the insurance requirement, thereby creating a conflict with federal law.

“If you adopted this theory of standing,” argued Neal K. Katyal, the acting United States solicitor general, “you would allow, for example, a state that was opposed to the war in Afghanistan to say our citizens should be exempt and file a lawsuit on that basis.”

The Fourth Circuit panel heard the appeals of two challenges to the health care act that yielded opposite results late last year.

In one challenge, by Attorney General Kenneth T. Cuccinelli II of Virginia, Judge Henry E. Hudson of Federal District Court in Richmond ruled that by requiring most Americans to buy insurance — a commercial product — the mandate exceeded Congress’s authority to regulate interstate commerce. In the other, filed by Liberty University, Judge Norman K. Moon of Federal District Court in Lynchburg, Va., found that the mandate fell comfortably within “well-settled principles” set by the Supreme Court.

The Virginia health care cases are the first of four scheduled for appellate hearings during the next five weeks. The Court of Appeals for the Sixth Circuit, in Cincinnati, will hear arguments on June 1 in the appeal of a ruling upholding the law. A week later, the Court of Appeals for the 11th Circuit, in Atlanta, will hear the Obama administration’s appeal of a Florida judge’s ruling that invalidated the entire act. That judge suspended his ruling until appellate courts could hear the case.

It is widely anticipated that the Supreme Court will ultimately settle the matter, although it is not clear which of several cases it might take. That may depend on how and when the appeals courts rule.

If, for instance, the three-judge panel rules against Virginia, the commonwealth expects to appeal directly to the Supreme Court without requesting a hearing before the full Fourth Circuit bench, Mr. Cuccinelli, a Republican, said on Tuesday. But if the Fourth Circuit rules that Virginia does not have standing to challenge the law, the Supreme Court could wait for a case that gives it a more focused look at the central issues.

In Tuesday’s hearing, Mr. Katyal slightly shifted the emphasis in the government’s defense of the health law. He tried to steer the judges away from a semantic focus on whether a failure to buy health insurance constituted activity or inactivity, a question that has divided the lower courts.

Past Supreme Court decisions have backed Congress’s authority under the Constitution’s Commerce Clause to regulate “activities” that have a substantial effect on interstate commerce. But the court has never considered whether the term can be defined so broadly as to include decisions not to do something.

Mr. Katyal argued instead that the activity being regulated by the health care law is merely the means of payment by Americans who will inevitably enter the health care market and who will shift costs to others if they are not insured.

“Congress is not asking people to buy something they would not otherwise buy,” Mr. Katyal said.

Mathew D. Staver, the dean of Liberty University’s law school, disputed that assertion. The health care act, Mr. Staver said, “forces inactive bystanders into the stream of commerce.”

Battle Over Health Care Law Shifts to Federal Appellate Courts

At Tuesday’s hearing, the United States Court of Appeals for the Fourth Circuit will consider a pair of contradictory rulings sent up from the lower courts. In one case, filed by Virginia’s attorney general, a federal district judge in Richmond ruled late last year that Congress had exceeded its authority by requiring most Americans to obtain health insurance. In the other, filed by Liberty University, a conservative Christian institution, a district judge sitting 100 miles away in Lynchburg, Va., upheld the insurance mandate.

If the appellate courts act quickly, the question of the health law’s constitutionality could land before the Supreme Court as soon as the next term, which opens in October.

With the lower courts divided, each side hopes to build a string of victories in the midlevel Courts of Appeals.

“We want to win as many of these as we can,” said Attorney General Kenneth T. Cuccinelli II of Virginia, a Republican. “If we have nothing but wins all the way up to the Supreme Court, there is an element of momentum, I think, where the justices consider what has gone on before the case came to them.”

Since the enactment of the Affordable Care Act in March 2010, 31 lawsuits have been filed to challenge it, according to the Justice Department, which is defending the Obama administration. Nine are awaiting action by Courts of Appeals, and nine are pending in federal district courts. The others have been dismissed.

Three district judges appointed by Democratic presidents have upheld the law while two Republican appointees have struck down part or all of it.

On June 1, the Court of Appeals for the Sixth Circuit in Cincinnati is scheduled to hear the appeal of a ruling in favor of the law. On June 8, the Court of Appeals for the 11th Circuit in Atlanta will review a Florida judge’s ruling that invalidated the entire act. That judge later suspended his own order until higher courts could settle the matter.

The Supreme Court recently turned down a request by Mr. Cuccinelli that it hear the case without review by the Court of Appeals.

In Tuesday’s hearing, a three-judge panel will first hear arguments in the case filed by Liberty University and then in the one filed by Mr. Cuccinelli. The makeup of the randomly selected panel will not be revealed until Tuesday morning.

With the addition of four appointees by President Obama, the Fourth Circuit bench now includes seven members named by Democratic presidents and seven named by Republicans. The loser before the three-judge panel may petition for a hearing before the entire court before taking the case to the Supreme Court.

The Obama administration will be represented in each of the appellate cases by Neal K. Katyal, the acting solicitor general.

Solicitors general more typically argue for the federal government before the Supreme Court. Although it is not unprecedented for them to appear before Courts of Appeals, Mr. Katyal’s assignment is seen as a nod to the significance of the case.

E. Duncan Getchell Jr., Virginia’s solicitor general, will speak for the commonwealth, as he did in the district court, and Liberty University will be represented by Mathew D. Staver, the dean of its law school.

The plaintiffs in the 11th Circuit case, including Republican officials from 26 states, will be represented by Paul D. Clement, a United States solicitor general under President George W. Bush. Mr. Clement recently resigned from King & Spalding after it withdrew its support for his defense of a federal law banning recognition of same-sex marriages.

Scores of politicians, economists and interest groups have filed friend-of-the-court briefs on both sides of the health care litigation.

The Virginia and Liberty University cases bear some differences. But both challenge the insurance requirement on the ground that it cannot be supported by the commerce clause of the United States Constitution, which gives Congress broad but not unlimited authority to regulate interstate commerce. Starting in 2014, the health care law would require most Americans to obtain policies or pay an income tax penalty.

The plaintiffs complain that the government has never before forced citizens to buy a commercial product. In the lower courts, arguments have centered on whether a choice to not buy insurance constitutes the kind of economic “activity” that the Supreme Court has, in the past, found subject to federal regulation.

The judges are also being asked to determine whether Virginia has legal standing to challenge the law, whether the insurance requirement can be supported under Congress’s authority to tax, whether it runs afoul of religious liberties, whether employers can be required to contribute to their workers’ health coverage, and whether a finding against one provision of the law should invalidate the entire act.

 

Battle Over Health Care Law Shifts to Federal Appellate Courts

At Tuesday’s hearing, the United States Court of Appeals for the Fourth Circuit will consider a pair of contradictory rulings sent up from the lower courts. In one case, filed by Virginia’s attorney general, a federal district judge in Richmond ruled late last year that Congress had exceeded its authority by requiring most Americans to obtain health insurance. In the other, filed by Liberty University, a conservative Christian institution, a district judge sitting 100 miles away in Lynchburg, Va., upheld the insurance mandate.

If the appellate courts act quickly, the question of the health law’s constitutionality could land before the Supreme Court as soon as the next term, which opens in October.

With the lower courts divided, each side hopes to build a string of victories in the midlevel Courts of Appeals.

“We want to win as many of these as we can,” said Attorney General Kenneth T. Cuccinelli II of Virginia, a Republican. “If we have nothing but wins all the way up to the Supreme Court, there is an element of momentum, I think, where the justices consider what has gone on before the case came to them.”

Since the enactment of the Affordable Care Act in March 2010, 31 lawsuits have been filed to challenge it, according to the Justice Department, which is defending the Obama administration. Nine are awaiting action by Courts of Appeals, and nine are pending in federal district courts. The others have been dismissed.

Three district judges appointed by Democratic presidents have upheld the law while two Republican appointees have struck down part or all of it.

On June 1, the Court of Appeals for the Sixth Circuit in Cincinnati is scheduled to hear the appeal of a ruling in favor of the law. On June 8, the Court of Appeals for the 11th Circuit in Atlanta will review a Florida judge’s ruling that invalidated the entire act. That judge later suspended his own order until higher courts could settle the matter.

The Supreme Court recently turned down a request by Mr. Cuccinelli that it hear the case without review by the Court of Appeals.

In Tuesday’s hearing, a three-judge panel will first hear arguments in the case filed by Liberty University and then in the one filed by Mr. Cuccinelli. The makeup of the randomly selected panel will not be revealed until Tuesday morning.

With the addition of four appointees by President Obama, the Fourth Circuit bench now includes seven members named by Democratic presidents and seven named by Republicans. The loser before the three-judge panel may petition for a hearing before the entire court before taking the case to the Supreme Court.

The Obama administration will be represented in each of the appellate cases by Neal K. Katyal, the acting solicitor general.

Solicitors general more typically argue for the federal government before the Supreme Court. Although it is not unprecedented for them to appear before Courts of Appeals, Mr. Katyal’s assignment is seen as a nod to the significance of the case.

E. Duncan Getchell Jr., Virginia’s solicitor general, will speak for the commonwealth, as he did in the district court, and Liberty University will be represented by Mathew D. Staver, the dean of its law school.

The plaintiffs in the 11th Circuit case, including Republican officials from 26 states, will be represented by Paul D. Clement, a United States solicitor general under President George W. Bush. Mr. Clement recently resigned from King & Spalding after it withdrew its support for his defense of a federal law banning recognition of same-sex marriages.

Scores of politicians, economists and interest groups have filed friend-of-the-court briefs on both sides of the health care litigation.

The Virginia and Liberty University cases bear some differences. But both challenge the insurance requirement on the ground that it cannot be supported by the commerce clause of the United States Constitution, which gives Congress broad but not unlimited authority to regulate interstate commerce. Starting in 2014, the health care law would require most Americans to obtain policies or pay an income tax penalty.

The plaintiffs complain that the government has never before forced citizens to buy a commercial product. In the lower courts, arguments have centered on whether a choice to not buy insurance constitutes the kind of economic “activity” that the Supreme Court has, in the past, found subject to federal regulation.

The judges are also being asked to determine whether Virginia has legal standing to challenge the law, whether the insurance requirement can be supported under Congress’s authority to tax, whether it runs afoul of religious liberties, whether employers can be required to contribute to their workers’ health coverage, and whether a finding against one provision of the law should invalidate the entire act.

 

Battle Over Health Care Law Shifts to Federal Appellate Courts

At Tuesday’s hearing, the United States Court of Appeals for the Fourth Circuit will consider a pair of contradictory rulings sent up from the lower courts. In one case, filed by Virginia’s attorney general, a federal district judge in Richmond ruled late last year that Congress had exceeded its authority by requiring most Americans to obtain health insurance. In the other, filed by Liberty University, a conservative Christian institution, a district judge sitting 100 miles away in Lynchburg, Va., upheld the insurance mandate.

If the appellate courts act quickly, the question of the health law’s constitutionality could land before the Supreme Court as soon as the next term, which opens in October.

With the lower courts divided, each side hopes to build a string of victories in the midlevel Courts of Appeals.

“We want to win as many of these as we can,” said Attorney General Kenneth T. Cuccinelli II of Virginia, a Republican. “If we have nothing but wins all the way up to the Supreme Court, there is an element of momentum, I think, where the justices consider what has gone on before the case came to them.”

Since the enactment of the Affordable Care Act in March 2010, 31 lawsuits have been filed to challenge it, according to the Justice Department, which is defending the Obama administration. Nine are awaiting action by Courts of Appeals, and nine are pending in federal district courts. The others have been dismissed.

Three district judges appointed by Democratic presidents have upheld the law while two Republican appointees have struck down part or all of it.

On June 1, the Court of Appeals for the Sixth Circuit in Cincinnati is scheduled to hear the appeal of a ruling in favor of the law. On June 8, the Court of Appeals for the 11th Circuit in Atlanta will review a Florida judge’s ruling that invalidated the entire act. That judge later suspended his own order until higher courts could settle the matter.

The Supreme Court recently turned down a request by Mr. Cuccinelli that it hear the case without review by the Court of Appeals.

In Tuesday’s hearing, a three-judge panel will first hear arguments in the case filed by Liberty University and then in the one filed by Mr. Cuccinelli. The makeup of the randomly selected panel will not be revealed until Tuesday morning.

With the addition of four appointees by President Obama, the Fourth Circuit bench now includes seven members named by Democratic presidents and seven named by Republicans. The loser before the three-judge panel may petition for a hearing before the entire court before taking the case to the Supreme Court.

The Obama administration will be represented in each of the appellate cases by Neal K. Katyal, the acting solicitor general.

Solicitors general more typically argue for the federal government before the Supreme Court. Although it is not unprecedented for them to appear before Courts of Appeals, Mr. Katyal’s assignment is seen as a nod to the significance of the case.

E. Duncan Getchell Jr., Virginia’s solicitor general, will speak for the commonwealth, as he did in the district court, and Liberty University will be represented by Mathew D. Staver, the dean of its law school.

The plaintiffs in the 11th Circuit case, including Republican officials from 26 states, will be represented by Paul D. Clement, a United States solicitor general under President George W. Bush. Mr. Clement recently resigned from King & Spalding after it withdrew its support for his defense of a federal law banning recognition of same-sex marriages.

Scores of politicians, economists and interest groups have filed friend-of-the-court briefs on both sides of the health care litigation.

The Virginia and Liberty University cases bear some differences. But both challenge the insurance requirement on the ground that it cannot be supported by the commerce clause of the United States Constitution, which gives Congress broad but not unlimited authority to regulate interstate commerce. Starting in 2014, the health care law would require most Americans to obtain policies or pay an income tax penalty.

The plaintiffs complain that the government has never before forced citizens to buy a commercial product. In the lower courts, arguments have centered on whether a choice to not buy insurance constitutes the kind of economic “activity” that the Supreme Court has, in the past, found subject to federal regulation.

The judges are also being asked to determine whether Virginia has legal standing to challenge the law, whether the insurance requirement can be supported under Congress’s authority to tax, whether it runs afoul of religious liberties, whether employers can be required to contribute to their workers’ health coverage, and whether a finding against one provision of the law should invalidate the entire act.