Opinion ID: 3048533
Heading Depth: 2
Heading Rank: 15

Heading: constitutionality of individual mandate

Text: UNDER THE COMMERCE POWER 99 With a firm understanding of the Act’s provisions, the congressional findings, and the Supreme Court’s Commerce Clause precedents, we turn to the central question at hand: whether the individual mandate is beyond the constitutional power granted to Congress under the Commerce Clause and Necessary and Proper Clause. In this Section, we begin with first principles. We then examine the subject matter the individual mandate seeks to regulate, and whether it can be readily categorized under the classes of activity the Supreme Court has previously identified. We follow with a discussion of the unprecedented nature of the individual mandate. Next, we analyze whether the individual mandate is a valid exercise of Congress’s power to regulate activities that substantially affect interstate commerce. In this regard, we appraise whether the government’s argument furnishes judicially enforceable limiting principles and address the individual mandate’s far-reaching implications for our federalist structure. Lastly, we consider the government’s alternative argument that the individual mandate is an essential part of a larger regulation of economic activity. We conclude that the individual mandate exceeds Congress’s commerce power.
100 As the Supreme Court has observed, “The judicial authority to determine the constitutionality of laws, in cases and controversies, is based on the premise that the ‘powers of the legislature are defined and limited; and that those limits may not be mistaken, or forgotten, the constitution is written.’” City of Boerne v. Flores, 521 U.S. 507, 516, 117 S. Ct. 2157, 2162 (1997) (quoting Marbury v. Madison, 5 U.S. (1 Cranch) 137, 176 (1803)). The judiciary is called upon not only to interpret the laws, but at times to enforce the Constitution’s limits on the power of Congress, even when that power is used to address an intractable problem. In enforcing these limits, we recognize that the Constitution established a federal government that is “‘acknowledged by all to be one of enumerated powers.’” Comstock, 560 U.S. at __, 130 S. Ct. at 1956 (quoting McCulloch, 17 U.S. at 405). In describing this constitutional structure, the Supreme Court has emphasized James Madison’s exposition in The Federalist No. 45: “‘The powers delegated by the proposed Constitution to the federal government are few and defined. Those which are to remain in the State governments are numerous and indefinite.’” Gregory v. Ashcroft, 501 U.S. 452, 458, 111 S. Ct. 2395, 2399 (1991) (quoting THE FEDERALIST NO. 45, at 292–93 (James Madison) (Clinton Rossiter ed., 1961)); see also Lopez, 514 U.S. at 552, 115 S. Ct. at 1626 (quoting same). In 101 that same essay, Madison noted that the commerce power was one such enumerated power: “The regulation of commerce, it is true, is a new power; but that seems to be an addition which few oppose, and from which no apprehensions are entertained.” THE FEDERALIST NO. 45, at 289 (James Madison) (E.H. Scott ed., 1898). The commerce power has since come to dominate federal legislation. The power to regulate commerce is the power “to prescribe the rule by which commerce is to be governed.” Gibbons, 22 U.S. at 196. As the Supreme Court instructs us, “The power of Congress in this field is broad and sweeping; where it keeps within its sphere and violates no express constitutional limitation it has been the rule of this Court, going back almost to the founding days of the Republic, not to interfere.” Katzenbach v. McClung, 379 U.S. 294, 305, 85 S. Ct. 377, 384 (1964). In fact, if the object of congressional legislation falls within the sphere contemplated by the Commerce Clause, “[t]hat power is plenary and may be exerted to protect interstate commerce no matter what the source of the dangers which threaten it.” Jones & Laughlin Steel Corp., 301 U.S. at 37, 57 S. Ct. at 624 (citation and quotation marks omitted). It is because of the breadth and depth of this power that even when the Supreme Court has blessed Congress’s most expansive invocations of the Commerce Clause, it has done so with a word of warning: “Undoubtedly the scope 102 of this power must be considered in the light of our dual system of government and may not be extended so as to embrace effects upon interstate commerce so indirect and remote that to embrace them, in view of our complex society, would effectually obliterate the distinction between what is national and what is local and create a completely centralized government.” Id. It is this dualistic nature of the Commerce Clause power—necessarily broad yet potentially dangerous to the fundamental structure of our government—that has led the Court to adopt a flexible approach to its application, one that is often difficult to apply. As Chief Justice Hughes noted, Whatever terminology is used, the criterion is necessarily one of degree and must be so defined. This does not satisfy those [who] seek for mathematical or rigid formulas. But such formulas are not provided by the great concepts of the Constitution such as ‘interstate commerce,’ ‘due process,’ ‘equal protection.’ In maintaining the balance of the constitutional grants and limitations, it is inevitable that we should define their applications in the gradual process of inclusion and exclusion. Santa Cruz Fruit Packing Co. v. NLRB., 303 U.S. 453, 467, 58 S. Ct. 656, 660 (1938); see also Lopez, 514 U.S. at 566, 115 S. Ct. at 1633 (“But, so long as Congress’ authority is limited to those powers enumerated in the Constitution, and so long as those enumerated powers are interpreted as having judicially enforceable outer limits, congressional legislation under the Commerce Clause always will engender ‘legal uncertainty.’”). 103 Thus, it is not surprising that Lopez begins not with categories or substantial effects tests, but rather “first principles,” reaffirming the “constitutionally mandated division of authority [that] ‘was adopted by the Framers to ensure protection of our fundamental liberties.’” 514 U.S. at 553, 115 S. Ct. at 1626 (citing Gregory, 501 U.S. at 458, 111 S. Ct. at 2400). While the substantial growth and development of Congress’s power under the Commerce Clause has been welldocumented, the Court has often reiterated that the power therein granted remains “subject to outer limits.” Id. at 557, 115 S. Ct. at 1628. When Congress oversteps those outer limits, the Constitution requires judicial engagement, not judicial abdication. The Supreme Court has placed two broad limitations on congressional power under the Commerce Clause. First, Congress’s regulation must accommodate the Constitution’s federalist structure and preserve “a distinction between what is truly national and what is truly local.” Id. at 567–68, 115 S. Ct. at 1634. Second, the Court has repeatedly warned that courts may not interpret the Commerce Clause in a way that would grant to Congress a general police power, “which the Founders denied the National Government and reposed in the States.” Morrison, 529 U.S. at 618, 120 S. Ct. at 1754; see also Lopez, 514 U.S. at 584, 115 S. Ct. at 1642 (Thomas, J., concurring) (“[W]e always have rejected readings 104 of the Commerce Clause and the scope of federal power that would permit Congress to exercise a police power; our cases are quite clear that there are real limits to federal power.”). Therefore, in determining if a congressional action is within the limits of the Commerce Clause, we must look not only to the action itself but also its implications for our constitutional structure. See Lopez, 514 U.S. at 563–68, 115 S. Ct. at 1632–34. While these structural limitations are often discussed in terms of federalism, their ultimate goal is the protection of individual liberty. See Bond v. United States, 564 U.S. __, __, 131 S. Ct. 2355, 2363 (2011) (“Federalism secures the freedom of the individual.”); New York v. United States, 505 U.S. at 181, 112 S. Ct. at 2431 (“The Constitution does not protect the sovereignty of States for the benefit of the States or state governments as abstract political entities . . . . To the contrary, the Constitution divides authority between federal and state governments for the protection of individuals.”). With this at stake, we examine whether Congress legislated within its constitutional boundaries in enacting the individual mandate.83 We begin this analysis with a “presumption of constitutionality,” meaning that “we invalidate a 83 As a preliminary matter, we note that the parties appear to agree that if the individual mandate is to be sustained, it must be under the third category of activities that Congress may regulate under its commerce power: i.e., “those activities that substantially affect interstate commerce.” Lopez, 514 U.S. at 559, 115 S. Ct. at 1630. 105 congressional enactment only upon a plain showing that Congress has exceeded its constitutional bounds.” Morrison, 529 U.S. at 607, 120 S. Ct. at 1748.
The parties contend that the answer to the question of the individual mandate’s constitutionality is straightforward. The government emphasizes that Congress intended to regulate the health insurance and health care markets to ameliorate the cost-shifting problem created by individuals who forego insurance yet at some time in the future seek health care for which they cannot pay. 42 U.S.C. § 18091(a)(1)(A), (H). One of the tools Congress employed to solve that problem is an economic mandate requiring Americans to purchase and continuously maintain health insurance. The government argues that the individual mandate is constitutional because it regulates “quintessentially economic” activity related to an industry of near universal participation, whereas the regulations in Lopez and Morrison touched on criminal conduct, which is not “in any sense of the phrase, economic activity.” Morrison, 529 U.S. at 613, 120 S. Ct. at 1751. The government submits that Congress has mandated only how Americans finance their inevitable health care needs. The plaintiffs respond that the plain text of the Constitution and Supreme Court precedent support the conclusion that “activity” is a prerequisite to valid 106 congressional regulation under the commerce power. The plaintiffs stress that Congress’s authority is to “regulate” commerce, not to compel individuals to enter into commerce so that the federal government may regulate them. The plaintiffs point out that by choosing not to purchase insurance, the uninsured are outside the stream of commerce. Indeed, the nature of the conduct is marked by the absence of a commercial transaction. Since they are not engaged in commerce, or activities associated with commerce, they cannot be regulated pursuant to the Commerce Clause. The plaintiffs emphasize that, in 220 years of constitutional history, Congress has never exercised its commerce power in this manner. Whereas the parties and many commentators have focused on this distinction between activity and inactivity, we find it useful only to a point. Beginning with the plain language of the text, the Commerce Clause gives Congress the power to “regulate Commerce.” U.S. CONST. art. I, § 8, cl. 3. The power to regulate commerce, of course, presupposes that something exists to regulate. In its first comprehensive discussion of the Commerce Clause, the Supreme Court in Gibbons attempted to define commerce, stating, “Commerce, undoubtedly, is traffic, but it is something more: it is intercourse. It describes the commercial intercourse between nations, and parts of nations, in all its branches, and is regulated by prescribing rules for carrying on that intercourse.” Gibbons, 107 22 U.S. at 189–90 (emphasis added). The nature of Chief Justice Marshall’s formulation presaged the Supreme Court’s tendency to describe commerce in very general terms, since an attempt to formulate a precise and all-encompassing definition would prove impractical. However, the Supreme Court has always described the commerce power as operating on already existing or ongoing activity. The Gibbons Court stated, “If Congress has the power to regulate it, that power must be exercised whenever the subject exists. If it exists within the States, if a foreign voyage may commence or terminate at a port within a State, then the power of Congress may be exercised within a State.” Id. at 195 (emphasis added). In its recent cases, the Supreme Court has continued to articulate Congress’s commerce authority in terms of “activity.” In Lopez, the Court identified “three broad categories of activity that Congress may regulate under its commerce power” and concluded that “possession of a gun in a local school zone is in no sense an economic activity.” 514 U.S. at 558, 567, 115 S. Ct. at 1629, 1634 (emphasis added); see also Raich, 545 U.S. at 26, 125 S. Ct. at 2211 (“[T]he CSA is a statute that directly regulates economic, commercial activity.” (emphasis added)); Morrison, 529 U.S. at 611, 120 S. Ct. at 1750 (“Lopez’s review of Commerce Clause case law demonstrates that in those cases where we have sustained federal regulation of intrastate activity based upon the 108 activity’s substantial effects on interstate commerce, the activity in question has been some sort of economic endeavor.” (emphasis added)). As our extensive discussion of the Supreme Court’s precedent reveals, Commerce Clause cases run the gamut of possible regulation. But the diverse fact patterns of Wickard, South-Eastern Underwriters, Heart of Atlanta Motel, Lopez, Morrison, and Raich share at least one commonality: they all involved attempts by Congress to regulate preexisting, freely chosen classes of activities. Nevertheless, we are not persuaded that the formalistic dichotomy of activity and inactivity provides a workable or persuasive enough answer in this case. Although the Supreme Court’s Commerce Clause cases frequently speak in activity-laden terms, the Court has never expressly held that activity is a precondition for Congress’s ability to regulate commerce—perhaps, in part, because it has never been faced with the type of regulation at issue here. We therefore must refine our understanding of the nature of the individual mandate and the subject matter it seeks to regulate. The uninsured have made a decision, either consciously or by default, to direct their financial resources to some other item or need than health insurance. Congress described “the activity” it sought to regulate as “economic and financial decisions about how and when health care is paid for, and when health insurance is purchased.” 42 U.S.C. 109 § 18091(a)(2)(A) (emphasis added). It deemed such decisions as activity that is “commercial and economic in nature.” Id. Congress linked the individual mandate to this decision: “In the absence of th[is] requirement, some individuals would make an economic and financial decision to forego health insurance coverage and attempt to self-insure . . . .” Id. That Congress casts the individual mandate as regulating economic activity is not surprising. In Morrison, the Supreme Court acknowledged that “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.” 529 U.S. at 613, 120 S. Ct. at 1751. Raich confirmed the continued viability of this distinction between economic and noneconomic activity in assessing Congress’s commerce authority. See 545 U.S. at 25–26, 125 S. Ct. at 2210–11. The parties here disagree about where the individual mandate falls within this “economic versus noneconomic activity” framework. On one hand, a decision not to purchase insurance and to self-insure for health care is a financial decision that has more of an economic patina than the gun possession in Lopez or the gender-motivated violence in Morrison. But whether such an economic decision constitutes economic activity as previously conceptualized by the Supreme Court is not so clear, nor do we find this sort of categorical thinking particularly helpful 110 in assessing the constitutionality of such an unprecedented congressional action. After all, in choosing not to purchase health insurance, the individuals regulated by the individual mandate are hardly involved in the “production, distribution, and consumption of commodities,” which was the broad definition of economics provided by the Raich Court.84 545 U.S. at 25, 125 S. Ct. at 2211 (citation and quotation marks omitted). Rather, to the extent the uninsured can be said to be “active,” their activity consists of the absence of such behavior, at least with respect to health insurance.85 Simply put, the individual mandate cannot be neatly classified under either the “economic activity” or “noneconomic activity” headings. This confirms the wisdom in the conclusion that the Court’s attempts throughout history to define by “semantic or formalistic categories those activities that were commerce and those that were not” are doomed to fail. Lopez, 514 U.S. at 569, 115 S. Ct. at 1635 (Kennedy, J., concurring). Compare United States v. 84 The fact that conduct may be said to have economic effects does not, by that fact alone, render the conduct “economic activity,” at least as defined by the Supreme Court. Lopez and Morrison make this observation apparent. Even the fact that conduct in some way relates to commerce does not, by itself, convert that conduct into economic activity. Indeed, the regulated activity in Lopez (firearm possession) directly related to an article of commerce (the firearm being possessed). The Supreme Court has emphasized that the relevant inquiry is the link between the regulated activity and its effects on interstate commerce. 85 The government correctly notes that many of the uninsured do actively consume health care, even though they are not participants in the health insurance market. We address this point at length later. 111 E.C. Knight Co., 156 U.S. 1, 13, 15 S. Ct. 249, 254 (1895) (approving manufacturing-commerce dichotomy), with Standard Oil Co. v. United States, 221 U.S. 1, 68–69, 31 S. Ct. 502, 519 (1911) (declaring manufacturing-commerce dichotomy “unsound”). See also Lopez, 514 U.S. at 572, 115 S. Ct. at 1636 (Kennedy, J., concurring) (noting “the Court’s recognition of the importance of a practical conception of the commerce power”); Wickard, 317 U.S. at 120, 63 S. Ct. at 87 (stating that “questions of the power of Congress are not to be decided by reference to any formula which would give controlling force to nomenclature such as ‘production’ and ‘indirect’”); Swift & Co. v. United States, 196 U.S. 375, 398, 25 S. Ct. 276, 280 (1905) (observing that “commerce among the states is not a technical legal conception, but a practical one, drawn from the course of business”). Yet, confusing though these dichotomies and doctrinal vacillations have been, they appear animated by one overarching goal: to provide courts with meaningful, judicially administrable limiting principles by which to assess Congress’s exercise of its Commerce Clause power. Properly formulated, we perceive the question before us to be whether the federal government can issue a mandate that Americans purchase and maintain health insurance from a private company for the entirety of their lives.86 These 86 Whether one describes the regulated individual’s decision as the financing of health care, self-insurance, or risk retention, the congressional mandate is to acquire and continuously 112 types of purchasing decisions are legion. Every day, Americans decide what products to buy, where to invest or save, and how to pay for future contingencies such as their retirement, their children’s education, and their health care. The government contends that embedded in the Commerce Clause is the power to override these ordinary decisions and redirect those funds to other purposes. Under this theory, because Americans have money to spend and must inevitably make decisions on where to spend it, the Commerce Clause gives Congress the power to direct and compel an individual’s spending in order to further its overarching regulatory goals, such as reducing the number of uninsureds and the amount of uncompensated health care. In answering whether the federal government may exercise this asserted power to issue a mandate for Americans to purchase health insurance from private companies, we next examine a number of issues: (1) the unprecedented nature of the individual mandate; (2) whether Congress’s exercise of its commerce authority affords sufficient and meaningful limiting principles; and (3) the far-reaching implications for our federalist structure. C. Unprecedented Nature of the Individual Mandate Both parties have cited extensively to previous Supreme Court opinions maintain health coverage. And unless the person is covered by a government-financed health program, the mandate is to purchase insurance from a private insurer. 113 defining the scope of the Commerce Clause. Economic mandates such as the one contained in the Act are so unprecedented, however, that the government has been unable, either in its briefs or at oral argument, to point this Court to Supreme Court precedent that addresses their constitutionality. Nor does our independent review reveal such a precedent. The Supreme Court has sustained Congress’s authority to regulate steamboat traffic, Gibbons, 22 U.S. 1; trafficking of lottery tickets across state lines, The Lottery Case, 188 U.S. 321, 23 S. Ct. 321 (1903); and carrying a woman across state lines for “immoral purposes,” Hoke v. United States, 227 U.S. 308, 320, 33 S. Ct. 281, 283 (1913). Through the Commerce Clause, Congress may prevent the interstate transportation of liquor, United States v. Simpson, 252 U.S. 465, 40 S. Ct. 364 (1920); punish an automobile thief who crosses state lines, Brooks v. United States, 267 U.S. 432, 45 S. Ct. 345 (1925); and prevent diseased herds of cattle from bringing their contagion from Georgia to Florida, Thornton v. United States, 271 U.S. 414, 46 S. Ct. 585 (1926). In the modern era, the Commerce Clause has been used to regulate labor practices, Jones & Laughlin Steel Corp., 301 U.S. 1, 57 S. Ct. 615; impose minimum working conditions, Darby, 312 U.S. 100, 61 S. Ct. 451; limit the production of wheat for home consumption, Wickard, 317 U.S. 111, 63 S. Ct. 82; 114 regulate the terms of insurance contracts, South-Eastern Underwriters, 322 U.S. 533, 64 S. Ct. 1162; prevent discrimination in hotel accommodations, Heart of Atlanta Motel, 379 U.S. 241, 85 S. Ct. 348, and restaurant services, Katzenbach, 379 U.S. 294, 85 S. Ct. 377; and prevent the home production of marijuana for medical purposes, Raich, 545 U.S. 1, 125 S. Ct. 2195. What the Court has never done is interpret the Commerce Clause to allow Congress to dictate the financial decisions of Americans through an economic mandate. Both the Congressional Budget Office (“CBO”) and the Congressional Research Service (“CRS”) have commented on the unprecedented nature of the individual mandate. When the idea of an individual mandate to purchase health insurance was first floated in 1994, the CBO stated that a “mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action.” SPEC. STUDIES DIV., CONG. BUDGET OFFICE, THE BUDGETARY TREATMENT OF AN INDIVIDUAL MANDATE TO BUY HEALTH INSURANCE 1 (1994) [hereinafter CBO MANDATE MEMO]. The CBO observed that Congress “has never required people to buy any good or service as a condition of lawful residence in the United States,” noting that “mandates typically apply to people as parties to economic transactions, rather than as members of society.” Id. at 1–2. Meanwhile, in reviewing the present legislation in 2009, the CRS warned: 115 Despite the breadth of powers that have been exercised under the Commerce Clause, it is unclear whether the clause would provide a solid constitutional foundation for legislation containing a requirement to have health insurance. Whether such a requirement would be constitutional under the Commerce Clause is perhaps the most challenging question posed by such a proposal, as it is a novel issue whether Congress may use this clause to require an individual to purchase a good or a service. JENNIFER STAMAN & CYNTHIA BROUGHER, CONG. RESEARCH SERV., R. 40725, REQUIRING INDIVIDUALS TO OBTAIN HEALTH INSURANCE: A CONSTITUTIONAL ANALYSIS 3 (2009). The fact that Congress has never before exercised this supposed authority is telling. As the Supreme Court has noted, “the utter lack of statutes imposing obligations on the States’ executive (notwithstanding the attractiveness of that course to Congress), suggests an assumed absence of such power.” Printz, 521 U.S. at 907–08, 117 S. Ct. at 2371; see also Va. Office for Prot. & Advocacy v. Stewart, 563 U.S. __, __, 131 S. Ct. 1632, 1641 (2011) (“Lack of historical precedent can indicate a constitutional infirmity.”); Alden v. Maine, 527 U.S. 706, 743–44, 119 S. Ct. 2240, 2261 (1999). Few powers, if any, could be more attractive to Congress than compelling the purchase of certain products. Yet even if we focus on the modern era, when congressional power under the Commerce Clause has been at its height, Congress still has not asserted this authority. Even in the face of a Great Depression, a World War, a Cold War, recessions, oil shocks, 116 inflation, and unemployment, Congress never sought to require the purchase of wheat or war bonds, force a higher savings rate or greater consumption of American goods, or require every American to purchase a more fuel efficient vehicle.87 See Printz, 521 U.S. at 905, 117 S. Ct. at 2370 (“[I]f . . . earlier Congresses avoided use of this highly attractive power, we would have reason to believe that the power was thought not to exist.”). Traditionally, Congress has sought to encourage commercial activity it favors while discouraging what it does not. This is instructive. Not only have prior congressional actions not asserted the power now claimed, they “contain some indication of precisely the opposite assumption.” Id. at 910, 117 S. Ct. at 2372. Instead of requiring action, Congress has sought to encourage it. The instances of such encouragement are ubiquitous, but the example of flood insurance provides a particularly relevant illustration of how the individual mandate departs from conventional exercises of congressional power. In passing the National Flood Insurance Act of 1968, Congress recognized that “from time to time flood disasters have created personal hardships and economic distress which have required unforeseen disaster relief measures and have placed an increasing burden on the Nation’s resources.” 42 U.S.C. 87 Compare the lack of legislation compelling activity to the long history of Congress forbidding activity. 117 § 4001(a)(1). Despite considerable expenditures on public programs designed to prevent floods, those programs had “not been sufficient to protect adequately against growing exposure to future flood losses.” Id. § 4001(a)(2). In response to this problem, however, Congress did not require everyone who owns a house in a flood plain to purchase flood insurance. In fact, Congress did not even require anyone who chooses to build a new house in a flood plain to buy insurance. Rather, Congress created a series of incentives designed to encourage voluntary purchase of flood insurance. These incentives included requiring flood insurance before the home owner could receive federal financial assistance or federally regulated loans. See id. § 4012a(a), (b)(1). Without an “individual mandate,” the flood insurance program has largely been a failure. See Bryant J. Spann, Note, Going Down for the Third Time: Senator Kerry’s Reform Bill Could Save the Drowning National Flood Insurance Program, 28 GA. L. REV. 593, 597 (1994) (“One of the most astounding facts to surface from the Midwestern flood of 1993 was that so few homeowners eligible for flood insurance actually had it. Of the states impacted by the flood, Illinois had the highest percentage of eligible households covered, with 8.7%.”). One key reason for this low participation is not surprising. “Disaster relief, as a political issue, is almost invincible. No politician wants to be on record as opposing 118 disaster relief, particularly for his or her own constituents.” Id. at 602. People living in a flood plain know that even if they do not have insurance, they can count on the virtually guaranteed availability of federal funds.88 Nevertheless, despite the unpredictability of flooding, the inevitability that floods will strike flood plains, and the cost shifting inherent in uninsured property owners seeking disaster relief funds, Congress has never taken the obvious and expedient step of invoking the power the government now argues it has and forcing all property owners in flood plains to purchase insurance.89 Contrast flood insurance with the very few instances of activity in which Congress has compelled Americans to engage solely as a consequence of being citizens living in the United States. Given the attractiveness of the power to compel behavior in order to solve important problems, we find it illuminating that Americans have, historically, been subject only to a limited set of personal mandates: serving on juries, registering for the draft, filing tax returns, and responding to the census. These mandates are in the nature of duties owed to the government attendant to citizenship, and they contain clear foundations in the 88 Compare this with the Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C. § 1395dd, which ensures public access to emergency medical services without regard to one’s ability to pay. 89 The contrast with the individual mandate is even more stark when we consider that property owners in flood plains have actually entered the housing market. 119 constitutional text.90 Additionally, all these mandates involve a citizen directly interacting with the government, whereas the individual mandate requires an individual to enter into a compulsory contract with a private company. In these respects, the individual mandate is a sharp departure from all prior exercises of federal power. The draft is an excellent example of this sort of duty, particularly as it is one upon which the Supreme Court has spoken. In the Selective Draft Law Cases, the Supreme Court reviewed challenges to the draft instituted in 1917 upon the entry of the United States into World War I. 245 U.S. 366, 38 S. Ct. 159 (1918). The Court rejected these challenges on several grounds, primarily based on the long history of the draft both in the United States and other nations. Id. at 379–87, 38 S. Ct. at 162–64. But it also pointed to the relationship between citizens and government: “It may not be doubted that the very [c]onception of a just government and its duty to the citizen includes the reciprocal obligation of the citizen to render military service in case of need and the right to compel it.” Id. at 378, 38 S. Ct. at 161. 90 See, e.g., U.S. CONST . art. I, § 2 (“[An] Enumeration shall be made within three Years after the first Meeting of the Congress of the United States, and within every subsequent Term of ten Years, in such Manner as they shall by Law direct.”); id. art. I, § 8, cl. 1 (“The Congress shall have Power To lay and collect Taxes”); id. art. I, § 8, cl. 12 (providing Congress with power “[t]o raise and support Armies”); id. art. III, § 2 (“The Trial of all Crimes, except in Cases of Impeachment, shall be by Jury.”). 120 It is striking by comparison how very different this economic mandate is from the draft. First, it does not represent the solution to a duty owed to the government as a condition of citizenship. Moreover, unlike the draft, it has no basis in the history of our nation, much less a long and storied one. Until Congress passed the Act, the power to regulate commerce had not included the authority to issue an economic mandate. Now Congress seeks not only the power to reach a new class of “activity”—financial decisions whose effects are felt some time in the future—but it wishes to do so through a heretofore untested power: an economic mandate. Having established the unprecedented nature of the individual mandate and the lack of any Supreme Court case addressing this issue, we are left to apply some basic Commerce Clause principles derived largely from Wickard, Lopez, Morrison, and Raich. D. Wickard and Aggregation It is not surprising that Wickard, which the Lopez Court considered “perhaps the most far reaching example of Commerce Clause authority over intrastate activity,”91 514 U.S. at 560, 115 S. Ct. at 1630, provides perhaps the best perspective on an economic mandate. Congress’s restrictions on Roscoe Filburn’s 91 Some have argued that Raich now represents the high-water mark of Congress’s commerce authority. We discuss Raich in more detail below. 121 wheat acreage potentially forced him to purchase wheat on the open market. In doing so, Congress was able to artificially inflate the price of wheat by simultaneously decreasing supply and increasing demand. But Wickard is striking not for its similarity to our present case, but in how different it is. Although Wickard represents the zenith of Congress’s powers under the Commerce Clause, the wheat regulation therein is remarkably less intrusive than the individual mandate. Despite the fact that Filburn was a commercial farmer92 and thus far more amenable to Congress’s commerce power than an ordinary citizen, the legislative act did not require him to purchase more wheat. Instead, Filburn had any number of other options open to him. He could have decided to make do with the amount of wheat he was allowed to grow. He could have redirected his efforts to agricultural endeavors that required less wheat. He could have even ceased part of his farming operations. The wheat-acreage regulation imposed by Congress, even though it lies at the outer bounds of the commerce power, was a limitation—not a mandate—and left Filburn with a choice. The Act’s economic mandate to purchase 92 In enacting the Agricultural Adjustment Act at issue in Wickard, Congress apparently sought to avoid reaching subsistence farmers whose production did not leave surplus for sale. Thus, it exempted small farms from the quota. See Wickard, 317 U.S. at 130 n.30, 63 S. Ct. at 92 n.30. In other words, Congress’s regulation only applied to suppliers operating in the stream of commerce, even though some of those market suppliers also consumed a portion of wheat at home. 122 insurance, on the contrary, leaves no choice and is more far-reaching. Although this distinction appears, at first blush, to implicate liberty concerns not at issue on appeal,93 in truth it strikes at the heart of whether Congress has acted within its enumerated power. Individuals subjected to this economic mandate have not made a voluntary choice to enter the stream of commerce, but instead are having that choice imposed upon them by the federal government. This suggests that they are removed from the traditional subjects of Congress’s commerce authority, in the same manner that the regulated actors in Lopez and Morrison were removed from the traditional subjects of Congress’s commerce authority by virtue of the noneconomic cast of their activity. This departure from commerce power norms is made all the more salient when we consider principles of aggregation, the chief addition of Wickard to the Commerce Clause canon. Aggregation may suffice to bring otherwise nonregulable, “trivial” instances of intrastate activity within Congress’s reach if the cumulative effect of this class of activity (i.e., the intrastate activity “taken together with that of many others similarly situated”) substantially affects interstate commerce. Wickard, 317 U.S. at 127–28, 63 S. Ct. at 90. Aggregation is 93 Among other counts, the district court dismissed the plaintiffs’ substantive due process challenge under the Fifth Amendment. Florida v. HHS, 716 F. Supp. 2d at 1161–62. That ruling is not on appeal. 123 a doctrine that allows Congress to apply an otherwise valid regulation to a class of intrastate activity it might not be able to reach in isolation.94 In Morrison and Lopez, the Supreme Court declined to apply aggregation to the noneconomic activity at issue, reasoning that “in every case where we have sustained federal regulation under the aggregation principle in [Wickard], the regulated activity was of an apparent commercial character.” Morrison, 529 U.S. at 611 n.4, 120 S. Ct. at 1750 n.4. The Court thereby resisted “additional expansion” of the substantial effects and aggregation doctrines. Lopez, 514 U.S. at 567, 115 S. Ct. at 1634. The question before us is whether Congress may regulate individuals outside the stream of commerce, on the theory that those “economic and financial decisions” to avoid commerce themselves substantially affect interstate commerce. Applying aggregation principles to an individual’s decision not to purchase a product would expand the substantial effects doctrine to one of unlimited scope. Given the economic reality of our national marketplace, any person’s decision not to purchase a good would, when aggregated, substantially affect interstate 94 Although not made explicit in Wickard, the courts have come to recognize aggregation as flowing from Congress’s powers to enact laws necessary and proper to effectuate its power under the Commerce Clause. See, e.g., Raich, 545 U.S. at 22, 125 S. Ct. at 2209; id. at 34, 125 S. Ct. at 2216 (Scalia, J., concurring); Katzenbach, 379 U.S. at 301–302, 85 S. Ct. at 382. 124 commerce in that good.95 From a doctrinal standpoint, we see no way to cabin the government’s theory only to decisions not to purchase health insurance. If an individual’s mere decision not to purchase insurance were subject to Wickard’s aggregation principle, we are unable to conceive of any product whose purchase Congress could not mandate under this line of argument.96 Although any decision not to purchase a good or service entails commercial consequences, this does not warrant the facile conclusion that Congress may therefore regulate these decisions pursuant to the Commerce Clause. See id. at 580, 115 S. Ct. at 1640 (Kennedy, J., concurring) (“In a sense any conduct in this interdependent world of ours has an ultimate commercial origin or consequence, but we have not yet said the commerce power may reach so far.”). Thus, even assuming that decisions not to buy insurance substantially affect interstate commerce, that fact alone hardly renders them a suitable subject for 95 Perhaps we can conceive of a purely intrastate good that is wholly insulated from the interstate market and, therefore, whose purchase Congress may not mandate even under the government’s sweeping extension of Wickard’s aggregation principle. To the extent such hypothetical goods exist, their number is vanishingly small. 96 The CBO suggested the possibility of this perilous course when it warned that an individual mandate to buy health insurance could “open the door to a mandate-issuing government taking control of virtually any resource allocation decision that would otherwise be left to the private sector . . . . In the extreme, a command economy, in which the President and the Congress dictated how much each individual and family spent on all goods and services, could be instituted without any change in total federal receipts or outlays.” CBO MANDATE MEMO , supra p.115, at 9. 125 regulation. See, e.g., Morrison, 529 U.S. at 617, 120 S. Ct. at 1754 (“We accordingly reject the argument that Congress may regulate noneconomic, violent criminal conduct based solely on that conduct’s aggregate effect on interstate commerce.” (emphasis added)). Instead, what matters is the regulated subject matter’s connection to interstate commerce. That nexus is lacking here. It is immaterial whether we perceive Congress to be regulating inactivity or a financial decision to forego insurance. Under any framing, the regulated conduct is defined by the absence of both commerce or even “the production, distribution, and consumption of commodities”—the broad definition of economics in Raich. 545 U.S. at 25, 125 S. Ct. at 2211. To connect this conduct to interstate commerce would require a “but-for causal chain” that the Supreme Court has rejected, as it would allow Congress to regulate anything. Morrison, 529 U.S. at 615, 120 S. Ct. at 1752. E. Broad Scope of Congress’s Regulation The scope of Congress’s regulation also affects the constitutional inquiry. Indisputably, the health insurance and health care industries involve, and substantially affect, interstate commerce, and Congress can regulate broadly in both those realms. Nonetheless, Congress, in exercising its commerce authority, must be careful not to sweep too broadly by including within the ambit of its 126 regulation activities that bear an insufficient nexus with interstate commerce. See Morrison, 529 U.S. at 613 & n.5, 120 S. Ct. at 1751–52 & n.5 (distinguishing invalidated statute from analogous statute requiring explicit interstate nexus); Lopez, 514 U.S. at 561–62, 115 S. Ct. at 1631 (same). In this regard, the individual mandate’s attempt to reduce the number of the uninsured and correct the cost-shifting problem is woefully overinclusive. The language of the mandate is not tied to those who do not pay for a portion of their health care (i.e., the cost-shifters). It is not even tied to those who consume health care. Rather, the language of the mandate is unlimited, and covers even those who do not enter the health care market at all. Although overinclusiveness may not be fatal for constitutional purposes, the Supreme Court has indicated that it is a factor to be added to the constitutional equation. For example, in Lopez the vast majority of the regulated behavior (firearm possession) did possess an interstate character.97 However, the Supreme Court 97 A staggering proportion of the firearms in America have been transported across state lines, and thus the possessions at issue in Lopez likely did have a sufficient nexus to interstate commerce—and thus, were within Congress’s regulatory authority. In the wake of Lopez, many defendants challenged their prosecutions under the felons-with-firearms statute—18 U.S.C. § 1202(a), later recodified as 18 U.S.C. § 922(g)—that the Supreme Court distinguished from § 922(q) by virtue of its jurisdictional element. In one such case, the government’s own expert witness testified that 95% of the firearms in the United States were transported across state lines. See Brent E. Newton, Felons, Firearms, and Federalism: Reconsidering Scarborough in Light of Lopez, 3 J. APP . PRAC. & PROCESS 671, 681–82 & n.53 (2001). Instructively, Congress took its cue from the Supreme Court after Lopez and amended the Gun-Free School Zones Act to require an explicit interstate nexus on an individualized basis. 127 ultimately found this fact insufficient to save the statute. Rather, the Supreme Court commented that an interstate-tying element in the statute itself “would ensure, through case-by-case inquiry, that the [activity] in question affects interstate commerce.”98 Lopez, 514 U.S. at 561, 115 S. Ct. at 1631. Here, the decision to forego insurance similarly lacks an established interstate tie or any “case-by-case inquiry.” See id. Aside from the categories of exempted individuals, the individual mandate is applied across-the-board without regard to whether the regulated individuals receive, or have ever received, uncompensated care—or, indeed, seek any care at all, either now or in the future.99 Thus, the Act contains no language “which might limit its reach to a discrete set of [activities] that additionally have an explicit connection with or effect on interstate commerce.” See id. at 562, 115 S. Ct. at 1631. The individual mandate sweeps too broadly in another way. Because the Specifically, Congress added a jurisdictional element to ensure that the charged individual’s particular firearm had moved in interstate or foreign commerce (or otherwise affected such commerce). See 18 U.S.C. § 922(q)(2)(A) (“It shall be unlawful for any individual knowingly to possess a firearm that has moved in or that otherwise affects interstate or foreign commerce at a place that the individual knows, or has reasonable cause to believe, is a school zone.” (emphasis added)). 98 The Lopez Court never stated that such an element was required, and nor do we. However, it is clearly a relevant constitutional factor that the Supreme Court instructs us to consider. The government’s argument ignores it completely. 99 Although health care consumption is pervasive, the plaintiffs correctly note that participation in the market for health care is far less inevitable than participation in markets for basic necessities like food or clothing. 128 Supreme Court’s prior Commerce Clause cases all deal with already-existing activity—not the mere possibility of future activity (in this case, health care consumption) that could implicate interstate commerce—the Court never had to address any temporal aspects of congressional regulation. However, the premise of the government’s position—that most people will, at some point in the future, consume health care—reveals that the individual mandate is even further removed from traditional exercises of Congress’s commerce power.100 It is true that Congress may, in some instances, regulate individuals who are consuming health care but not themselves causing the cost-shifting problem. Cf. Raich, 545 U.S. at 17, 125 S. Ct. at 2206 (“We have never required Congress to legislate with scientific exactitude.”); id. at 22, 125 S. Ct. at 2209 (“That the regulation ensnares some purely intrastate activity is of no moment.”). As the plaintiffs acknowledged at oral argument, when the uninsured actually enter the 100 The dissent attempts to sidestep the temporal leap problem by citing Consolidated Edison Co. v. NLRB for the proposition that Congress may take “reasonable preventive measures” to avoid future disruptions to interstate commerce. 305 U.S. 197, 222, 59 S. Ct. 206, 213 (1938). Consolidated Edison, of course, is wholly inapposite to this case, since Congress was regulating the labor practices of utility companies (1) fully engaged in the stream of commerce and (2) presently supplying economic services to instrumentalities of interstate commerce, such as railroads and steamships. Id. at 220–22, 59 S. Ct. at 213. Even so, the dissent’s argument proves far too much. After all, by the dissent’s reasoning, Congress could clearly reach the gun possession at issue in Lopez, since firearms are (1) objects of everyday commercial transactions and (2) are daily used to disrupt interstate commerce. See Lopez, 514 U.S. at 602–03, 115 S. Ct. at 1651 (Stevens, J., dissenting) (“Guns are both articles of commerce and articles that can be used to restrain commerce. Their possession is the consequence, either directly or indirectly, of commercial activity.”). Indeed, Antonio Lopez himself was paid $40 to traffic the gun for which he was charged under § 922(q). United States v. Lopez, 2 F.3d 1342, 1345 (5th Cir. 1995). 129 stream of commerce and consume health care, Congress may regulate their activity at the point of consumption. But the individual mandate does not regulate behavior at the point of consumption. Indeed, the language of the individual mandate does not truly regulate “how and when health care is paid for.” 42 U.S.C. § 18091(a)(2)(A). It does not even require those who consume health care to pay for it with insurance when doing so. Instead, the language of the individual mandate in fact regulates a related, but different, subject matter: “when health insurance is purchased.” Id. If an individual’s participation in the health care market is uncertain, their participation in the insurance market is even more so. In sum, the individual mandate is breathtaking in its expansive scope. It regulates those who have not entered the health care market at all. It regulates those who have entered the health care market, but have not entered the insurance market (and have no intention of doing so). It is overinclusive in when it regulates: it conflates those who presently consume health care with those who will not consume health care for many years into the future. The government’s position amounts to an argument that the mere fact of an individual’s existence substantially affects interstate commerce, and therefore Congress may regulate them at every point of their life. This theory affords no limiting principles in 130 which to confine Congress’s enumerated power. F. Government’s Proposed Limiting Principles “We pause to consider the implications of the Government’s arguments.” Lopez, 514 U.S. at 564, 115 S. Ct. at 1632. The government clearly appreciates the far-reaching implications of the individual mandate. The government has struggled to avoid the conclusion that Congress may order Americans’ other economic decisions through the use of economic mandates. At oral argument, the government’s counsel specifically disclaimed the argument that Congress could compel a person to purchase insurance solely on the basis of his financial decision to spend his money elsewhere. Rather, the government seems to view an economic mandate as an emergency tool of sorts, for use in extreme and unique situations and only to the extent the underlying regulated conduct meets a number of factbased criteria. The government submits that health care and health insurance are factually unique and not susceptible of replication due to: (1) the inevitability of health care need; (2) the unpredictability of need; (3) the high costs of health care; (4) the federal requirement that hospitals treat, until stabilized, individuals with emergency medical conditions, regardless of their ability to pay;101 (5) and 101 See EMTALA, 42 U.S.C. § 1395dd. In this regard, the plaintiffs point out that the government’s contention amounts to a bootstrapping argument. Under the government’s theory, 131 associated cost-shifting. The first problem with the government’s proposed limiting factors is their lack of constitutional relevance.102 These five factual criteria comprising the government’s “uniqueness” argument are not limiting principles rooted in any constitutional understanding of the commerce power. Rather, they are ad hoc factors that—fortuitously—happen to apply to the health insurance and health care industries. They speak more to the complexity of the problem being regulated than the regulated decision’s relation to interstate commerce. They are not limiting principles, but limiting circumstances. Apparently recognizing that these factors appear in many subjects worthy of regulation, the government acknowledged at oral argument that the mere presence of many of these factors is not sufficient. Presented with three examples of Congress can enlarge its own powers under the Commerce Clause by legislating a market externality into existence, and then claiming an extra-constitutional fix is required. 102 The Supreme Court has rejected similar calls for a reprieve from Commerce Clause restraints based upon the ostensible uniqueness or gravity of the problem being regulated. For instance, Justice Breyer’s dissent in Lopez attempted to deflect the majority’s focus on limiting principles—specifically, its statement that upholding § 922(q) would enable the federal government to “regulate any activity that it found was related to the economic productivity of individual citizens,” 514 U.S. at 564, 115 S. Ct. at 1632—by arguing that § 922(q) “is aimed at curbing a particularly acute threat” and that “guns and education are incompatible” in a “special way.” Id. at 624, 115 S. Ct. at 1661 (Breyer, J., dissenting) (emphasis added). The dissent further opined that gun possession in schools embodied “the rare case . . . [when] a statute strikes at conduct that (when considered in the abstract) seems so removed from commerce, but which (practically speaking) has so significant an impact upon commerce.” Id. at 624, 115 S. Ct. at 1662 (emphasis added). The majority dismissed these “suggested limitations,” however, characterizing them as “devoid of substance.” Id. at 564, 115 S. Ct. at 1632 (majority opinion). 132 industries characterized by some or all of these market deficiencies—elder care, other types of insurance, and the energy market—the government argued that an economic mandate in these three settings is distinguishable. However, virtually all forms of insurance entail decisions about timing and planning for unpredictable events with high associated costs—insurance protecting against loss of life, disability from employment, business interruption, theft, flood, tornado, and other natural disasters, long-term nursing care requirements, and burial costs. Under the government’s proposed limiting principles, there is no reason why Congress could not similarly compel Americans to insure against any number of unforeseeable but serious risks.103 High costs and cost-shifting in premiums are simply not limited to hospital care, but occur when individuals are disabled, cannot work, experience an accident, need nursing care, die, and myriad other insurance-related contingencies. This gives rise to a second fatal problem with the government’s proposed limits: administrability. We are at a loss as to how such fact-based criteria can serve as the sort of “judicially enforceable” limitations on the commerce power 103 The government essentially argues that anyone creates a cost-shifting risk by virtue of being alive, since they may one day be injured or sick and seek care that they do not pay for. Therefore, Congress can compel the purchase of health insurance, from birth to death, to protect against such risks. This expansive theory could justify the compelled purchase of innumerable forms of insurance, however. To give but one example, Congress could undoubtedly require every American to purchase liability insurance, lest the consequences of their negligence or inattention lead to unfunded costs (medical and otherwise) passed on to others in the future. 133 that the Supreme Court has repeatedly emphasized as necessary to that enumerated power. Lopez, 514 U.S. at 566, 115 S. Ct. at 1633; see also Morrison, 529 U.S. at 608 n.3, 120 S. Ct. at 1749 n.3 (rejecting dissent’s “remarkable theory that the commerce power is without judicially enforceable boundaries”). We are loath to invalidate an act of Congress, and do so only after extensive circumspection. But the role that the Court would take were we to adopt the position of the government is far more troublesome. Were we to adopt the “limiting principles” proffered by the government, courts would sit in judgment over every economic mandate issued by Congress, determining whether the level of participation in the underlying market, the amount of cost-shifting, the unpredictability of need, or the strength of the moral imperative were enough to justify the mandate. But the commerce power does not admit such limitations; rather it “is complete in itself, may be exercised to its utmost extent, and acknowledges no limitations, other than are prescribed in the constitution.” Gibbons, 22 U.S. at 196. If Congress may compel individuals to purchase health insurance from a private company, it may similarly compel the purchase of other products from private industry, regardless of the “unique conditions” the government cites as warrant for Congress’s regulation here. See Government’s Opening Br. at 19. Moreover, the government’s insistence that we defer to Congress’s fact 134 findings underscores the lack of any judicially enforceable stopping point to the government’s “uniqueness” argument. Presumably, a future Congress similarly would be able to articulate a unique problem requiring a legislative fix that entailed compelling Americans to purchase a certain product from a private company. The government apparently seeks to set the terms of the limiting principles courts should apply, and then asks that we defer to Congress’s judgment about whether those conditions have been met. The Supreme Court has firmly rejected such calls for judicial abdication in the Commerce Clause realm. See Lopez, 514 U.S. at 557 n.2, 115 S. Ct. at 1629 n.2 (“‘[W]hether particular operations affect interstate commerce sufficiently to come under the constitutional power of Congress to regulate them is ultimately a judicial rather than a legislative question, and can be settled finally only by this Court.’” (quoting Heart of Atlanta Motel, 379 U.S. at 273, 85 S. Ct. at 366 (Black, J., concurring))). At root, the government’s uniqueness argument relies upon a convenient sleight of hand to deflect attention from the central issue in the case: what is the nature of the conduct being regulated by the individual mandate, and may Congress reach it? Because an individual’s decision to forego purchasing a product is so incongruent with the “activities” previously reached by Congress’s commerce power, the government attempts to limit the individual mandate’s far- 135 reaching implications. Accordingly, the government adroitly and narrowly redefines the regulated activity as the uninsured’s health care consumption and attendant cost-shifting, or the timing and method of payment for such consumption.104 The government’s reluctance to define the conduct being regulated as the decision to forego insurance is understandable. After all, if the decision to forego purchasing a product is deemed “economic activity” (merely because it is inevitable that an individual in the future will consume in a related market), then decisions not to purchase a product would be subject to the sweeping doctrine of aggregation, and such no-purchase decisions of all Americans would fall within the federal commerce power. Consequently, the government could no longer fall back on “uniqueness” as a limiting factor, since Congress could enact purchase mandates no matter how pedestrian the relevant product market. As an inferior court, we may not craft new dichotomies—“uniqueness” versus “non-uniqueness,” or “cost-shifting” versus “non-cost-shifting”—not recognized by Supreme Court doctrine. To do so would require us to fabricate out 104 The dissent adopts the government’s position. See Dissenting Op. at 227 (describing “the relevant conduct targeted by Congress” as “the uncompensated consumption of health care services by the uninsured”); id. at 235 (stating that “many of the[] uninsured currently consume health care services for which they cannot or do not pay” and “[t]his is, in every real and meaningful sense, classic economic activity”); id. at 214 (“In other words, the individual mandate is the means Congress adopted to regulate the timing and method of individuals’ payment for the consumption of health care services.”). 136 of whole cloth a five-factor test that lacks any antecedent in the Supreme Court’s Commerce Clause jurisprudence. Thus, not only do the “uniqueness” factors lack judicial administrability, present Commerce Clause doctrine prohibits inferior courts, like us, from applying them anyway. Ultimately, the government’s struggle to articulate cognizable, judicially administrable limiting principles only reiterates the conclusion we reach today: there are none. G. Congressional Findings This brings us to the congressional findings. See 42 U.S.C. § 18091(a)(1)–(3). We look to congressional findings to help us “evaluate the legislative judgment that the activity in question substantially affected interstate commerce.” Lopez, 514 U.S. at 549, 115 S. Ct. at 1632. Here, tracking the language of Supreme Court decisions, the congressional findings begin with the statement that the individual insurance mandate “is commercial and economic in nature” and “substantially affects interstate commerce.” 42 U.S.C. § 18091(a)(1). Of course, the relevant inquiry is not whether the regulation itself substantially affects interstate commerce but rather whether the underlying activity being regulated substantially affects interstate commerce. 137 Later on, the findings do ground the individual mandate in Congress’s effort to address this multi-step cost-shifting scenario: (1) some uninsureds consume health care; (2) in turn, some of them do not pay their full medical costs and instead shift them to medical providers; (3) medical providers thereafter shift these costs to “private insurers”; and (4) private insurers then shift them to insureds through higher premiums.105 Id. § 18091(a)(2). The average annual premium increase is $1,000 for insured families, id., and $400 for individuals.106 The findings state that the mandate will reduce the number of the uninsured and the $43 billion cost-shifting and thereby “lower health insurance premiums.”107 Id. § 18091(a)(2)(F). Of course, “the existence of congressional findings is not sufficient, by itself, to sustain the constitutionality of Commerce Clause legislation.” Morrison, 105 The parties and amici use the shorthand terms “cost-shifting,” “cost-shifters,” or “freeriders” to describe these problems. 106 See Families USA, supra note 8. 107 Experts debate whether the Act will accomplish its premium-lowering objective. According to even the CBO, “Under PPACA and the Reconciliation Act, premiums for health insurance in the individual market will be somewhat higher than they would otherwise be . . . mostly because the average insurance policy in that market will cover a larger share of enrollees’ costs for health care and provide a slightly wider range of benefits.” CONG . BUDGET OFFICE , AN ANALYSIS OF HEALTH INSURANCE PREMIUMS UNDER THE PATIENT PROTECTION AND AFFORDABLE CARE ACT 8 (2009). The CBO estimates the Act will cause costs for health insurance in the individual market to rise by 27% to 30% over current levels in 2016, due to the broadened coverage achieved by the insurance market reforms. Id. at 6. For the purpose of our analysis, however, we accept the congressional finding that cost-shifters lead to higher premiums. 138 529 U.S. at 614, 120 S. Ct. at 1752. Rather, the Supreme Court has insisted that courts examine congressional findings regarding substantial effects. See Lopez, 514 U.S. at 557 n.2, 115 S. Ct. at 1629 n.2 (“‘[S]imply because Congress may conclude that a particular activity substantially affects interstate commerce does not necessarily make it so.’” (quoting Hodel, 452 U.S. at 311, 101 S. Ct. at 2391 (Rehnquist, J., concurring))). As a preliminary matter, we recount what the record reveals regarding the cost-shifting effects of the uninsured. To the extent the data show anything, the data demonstrate that the cost-shifters are largely persons who either (1) are exempted from the mandate, (2) are excepted from the mandate penalty, or (3) are now covered by the Act’s Medicaid expansion. For example, illegal aliens and other nonresidents are cost-shifters ($8.1 billion, or 18.9% of the $43 billion),108 but they are exempted from the individual mandate entirely. 26 U.S.C. § 5000A(d)(3). Low-income persons are the largest segment of cost-shifters ($15 billion, or 34.8% of the $43 billion),109 but they are covered by the Act’s Medicaid expansion or excepted from the mandate penalty. 108 See Br. of Amici Curiae Economists in Support of Plaintiffs at 11 & app. A (summarizing their calculations based on the MEPS data set). 109 See Br. of Amici Curiae Economists in Support of Plaintiffs at 11 & app. A (summarizing their calculations based on the MEPS data set). 139 Id. § 5000A(e)(1), (2) (excepting individuals (1) whose premium contribution exceeds 8% of household income or (2) whose household income is below the specified income tax filing threshold). Previously, the uninsured with preexisting health conditions sought, but were denied, coverage and ended up in the costshifting pool ($8.7 billion, or 20.1%).110 However, the Act’s insurance reforms now guarantee them coverage and move them out of the future cost-shifting pool. Already-insured persons who do not pay their out-of-pocket costs (such as copayments and deductibles) are cost-shifters ($3.3 billion, or 7.6%),111 but they are already covered by insurance without the mandate. In addition, the cost-shifter uninsureds who cannot pay the average $2,000 medical bill also cannot pay the average $4,500 premium,112 yielding another disconnect. In reality, the primary persons regulated by the individual mandate are not cost-shifters but healthy individuals who forego purchasing insurance. The Act 110 See Br. of Amici Curiae Economists in Support of Plaintiffs at 11 & app. A (summarizing their calculations based on the MEPS data set). 111 See Br. of Amici Curiae Economists in Support of Plaintiffs at 11 & app. A (summarizing their calculations based on the MEPS data set). 112 As noted earlier, the uninsureds’ average medical care costs were $2,000 in 2007 and $1,870 in 2008. Some uninsureds incur a larger expense, some a smaller expense, and some no expense at all. We use the average cited in the Brief of the Amici Curiae Economists in Support of the Government, at 16, which is based on the MEPS tables. The CBO estimates that in 2016 the annual premium for a bronze level plan, even in the Exchanges, will average $4,500–5,000 for individuals and $12,000–12,500 for a family policy. Letter from Douglas Elmendorf, Director, Cong. Budget Office, to Olympia Snowe, U.S. Senator (Jan. 11, 2010), available at http://www.cbo.gov/ftpdocs/108xx/doc10884/01-11-Premiums_for_Bronze_Plan.pdf. 140 confirms as much. To help private insurers, the congressional findings acknowledge that the individual mandate seeks to “broaden the health insurance risk pool to include healthy individuals,” to “minimize adverse selection,”113 to increase “the size of purchasing pools,” and to promote “economies of scale.” 42 U.S.C. § 18091(a)(2)(I), (J). The individual mandate forces healthy and voluntarily uninsured individuals to purchase insurance from private insurers and pay premiums now in order to subsidize the private insurers’ costs in covering more unhealthy individuals under the Act’s reforms. Congress sought to mitigate its reforms’ regulatory costs on private insurers114 by compelling healthy Americans outside the insurance market to enter the private insurance market and buy the insurers’ products. This starkly evinces how the Act is forcing market entry by those outside the market. Nevertheless, we need not, and do not, rely on the factual disparity between the persons regulated by the individual mandate and the cost-shifting problem. 113 Distinguished economists have filed helpful briefs on both sides of the case. While they disagree on some things, they agree about the theory of adverse selection. They agree some relatively healthy people refrain from, or opt out of, buying health insurance more often than people who are unhealthy or sick seek insurance. This results in a smaller and less healthy pool of insured persons for private insurance companies. Br. of Amici Curiae Economists in Support of the Government at 17–18; Br. of Amici Curiae Economists in Support of Plaintiffs at 13–16. 114 As explained above, the Act requires private insurers (1) to cover the unhealthy and (2) to price that coverage, not on actuarial risks or basic economic pricing decisions, but on community-rated premiums without regard to health status. 42 U.S.C. § 300gg-1(a). 141 After all, courts “need not determine whether respondents’ activities, taken in the aggregate, substantially affect interstate commerce in fact, but only whether a ‘rational basis’ exists for so concluding.”115 Raich, 545 U.S. at 22, 125 S. Ct. at 2208 (emphasis added). The government would have this be the end of the constitutional inquiry. But the government skips important analytical steps. Rational basis review is not triggered by the mere fact of Congress’s invocation of Article I power; rather, the Supreme Court has applied rational basis review to a more specific question under the Commerce Clause: whether Congress has a “rational basis” for concluding that the regulated “activities, when taken in the aggregate, substantially affect interstate commerce.”116 Id. (emphasis added). As discussed in subsection D, supra, courts must initially assess whether the subject matter 115 Notably, the Lopez Court recognized the same “rational basis” level of review as Raich. See Lopez, 514 U.S. at 557, 115 S. Ct. at 1629 (stating that, since the New Deal, the Supreme Court has “undertaken to decide whether a rational basis existed for concluding that a regulated activity sufficiently affected interstate commerce”). Raich did not adopt a more deferential review of congressional legislation than prior cases, as the Supreme Court itself acknowledged. See 545 U.S. at 22, 125 S. Ct. at 2208 (collecting cases). 116 Every case the Raich Court cited for rational basis review is a substantial effects case. See 545 U.S. at 22, 125 S. Ct. at 2208 (citing Lopez, 514 U.S. at 557, 115 S. Ct. 1624; Hodel, 452 U.S. at 276–80, 101 S. Ct. 2352; Perez, 402 U.S. at 155–56, 91 S. Ct. 1357; Katzenbach, 379 U.S. at 299–301, 85 S. Ct. 377; Heart of Atlanta Motel, 379 U.S. at 252–53, 85 S. Ct. 348). In such contexts, courts will accord significant deference to Congress’s assessment of whether an activity’s cumulative effect on interstate commerce is “substantial” or some lesser quantum. This is an altogether separate question from (1) whether a regulated activity is amenable to aggregation analysis at all and (2) the extent of the inferential leap needed to connect the regulated activity to the effects on interstate commerce. 142 targeted by the regulation is suitable for aggregation in the first place. Relatedly, courts, in the rational basis inquiry, must also examine whether the link between the regulated activity and interstate commerce is too attenuated, lest there be no discernible stopping point to Congress’s commerce power.117 See Lopez, 514 U.S. at 562–68, 115 S. Ct. at 1630–34. The wholesale deference the government would have us apply here cannot be squared with the Supreme Court’s decisions in Morrison and Lopez. Here, “Congress’ findings are substantially weakened by the fact that they rely so heavily on a method of reasoning that [courts] have already rejected as unworkable if we are to maintain the Constitution’s enumeration of powers.” Morrison, 529 U.S. at 615, 120 S. Ct. at 1752. It is highly instructive that the Lopez and Morrison Courts rejected a similar cost-shifting theory now propounded by the government. In examining the actual relationship between gun 117 Compare Raich, 545 U.S. at 22, 125 S. Ct. at 2209 (“[W]e have no difficulty concluding that Congress had a rational basis for believing that failure to regulate the intrastate manufacture and possession of marijuana would leave a gaping hole in the CSA.”), Heart of Atlanta Motel, 379 U.S. at 253, 85 S. Ct. at 355 (referring to “overwhelming evidence that discrimination by hotels and motels impedes interstate travel”), and Wickard, 317 U.S. at 128, 63 S. Ct. at 91 (“[A] factor of such volume and variability as home-consumed wheat would have a substantial influence on price and market conditions.”), with Morrison, 529 U.S. at 615, 120 S. Ct. at 1752 (rejecting the government’s invitation “to follow the but-for causal chain from the initial occurrence of violent crime . . . to every attenuated effect upon interstate commerce”), and Lopez, 514 U.S. at 564, 115 S. Ct. at 1632 (“[I]f we were to accept the Government’s arguments, we are hard pressed to posit any activity by an individual that Congress is without power to regulate.”). 143 possession and interstate commerce, the Lopez Court refused to accept what it referred to as the government’s “cost of crime” theory. 514 U.S. at 564, 115 S. Ct. at 1632. It did so despite the government’s argument that the “costs of violent crime are substantial, and, through the mechanism of insurance, those costs are spread throughout the population.” Id. at 563–64, 115 S. Ct. at 1632 (emphasis added). Similarly, in Morrison the Supreme Court considered a stockpile118 of congressional findings attesting to the link between domestic violence and medical costs frequently borne by third parties. See, e.g., 529 U.S. at 629–36, 120 S. Ct. at 1760–64 (Souter, J., dissenting); see also id. at 632, 120 S. Ct. at 1762 (“‘Over 1 million women in the United States seek medical assistance each year for injuries sustained [from] their husbands or other partners.’” (quoting S. Rep. No. 101-545, at 37 (1990))); id. (“‘[E]stimates suggest that we spend $5 to $10 billion a year on health care, criminal justice, and other social costs of domestic violence.’” (quoting S. Rep. No. 103-138, at 41 (1993))). In Morrison, the Supreme Court also recounted Congress’s express finding 118 In Morrison, “[t]he congressional findings that accompanied VAWA were so voluminous that they were removed from the text of the statute and placed in a conference report to avoid cluttering the United States Code.” Melissa Irr, Note, United States v. Morrison; An Analysis of the Diminished Effect of Congressional Findings in Commerce Clause Jurisprudence and a Criticism of the Abandonment of the Rational Basis Test, 62 U. PITT . L. REV . 815, 824 (2001). 144 that gender-motivated violence substantially affected interstate commerce “‘by deterring potential victims from traveling interstate, from engaging in employment in interstate business, and from transacting with business, and in places involved in interstate commerce; . . . by diminishing national productivity, increasing medical and other costs, and decreasing the supply of and the demand for interstate products.’” Id. at 615, 120 S. Ct. at 1752 (majority opinion) (emphasis added) (quoting H.R. Conf. Rep. No. 103-711, at 385 (1994)). The Morrison Court did not dispute the above figures about medical costs, but instead considered them largely extraneous to the threshold question of whether the subject matter of the regulation had a sufficient nexus to interstate commerce. See id. at 617, 120 S. Ct. at 1754. In both Lopez and Morrison, the Supreme Court determined that the government’s cost-shifting argument provided too attenuated a link to Congress’s commerce power. Under such a cost-shifting theory, “it is difficult to perceive any limitation on federal power, even in areas such as criminal law enforcement or education where States historically have been sovereign.” Lopez, 514 U.S. at 564, 115 S. Ct. at 1632. For example, we harbor few doubts that an individual’s decisions about “marriage, divorce, and child custody,” if aggregated, would have substantial 145 effects on interstate commerce. See id. at 564, 115 S. Ct. at 1632. Yet, the mere fact of an activity’s substantial effects on interstate commerce does not thereby render that activity an appropriate subject for Congress’s plenary commerce authority. Such a holding would require the Supreme Court to overturn Lopez and Morrison. We see no reason why the inferential leaps in this case are any less attenuated than those in Lopez and Morrison. The cost-shifting accompanying the criminal acts of violence at issue in Lopez and Morrison—hospital bills borne by third parties, property damage and insurance consequences, law enforcement expenditures and incarceration costs—is at least as apparent as the multi-step costshifting scenario associated with the medically uninsured. Meanwhile, in all three cases, the regulated conduct giving rise to the cost-shifting is divorced from a commercial transaction or the “production, distribution, and consumption of commodities.” Raich, 545 U.S. at 26, 125 S. Ct. at 2211. At best, we can say that the uninsured may, at some point in the unforeseeable future, create that cost-shifting consequence. Yet this readily leads to a scenario where we must “pile inference upon inference” to sustain Congress’s legislation, a practice the Supreme Court admonishes us to avoid. See Lopez, 514 U.S. at 567, 115 S. Ct. at 1634. If anything, the temporal aspects present here, but 146 not in Lopez or Morrison, render the regulated “activity” even further remote.119 We next explain how the individual mandate impairs important federalism concerns. H. Areas of Traditional State Concern Before examining the states’ traditional role in regulating insurance and health care, we fully recognize that Congress has the power under the Commerce Clause to regulate broadly in those arenas. In fact, Congress has legislated expansively and constitutionally in the fields of insurance and health care. See, e.g., Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), Pub. L. No. 104-191, 110 Stat. 1936 (1996); Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”), Pub. L. No. 99-272, 100 Stat. 82 (1986); Employee Retirement Income Security Act of 1974 (“ERISA”), Pub. L. No. 93406, 88 Stat. 829 (1974); Social Security Amendments of 1965, Pub. L. No. 89-97, 119 The dissent identifies an economic effect—cost-shifting—and essentially defines that as the activity being regulated. But the dissent’s conflation of activity and effect is sheer question begging. It is no wonder, then, that the dissent makes the breathtaking assertion that there is not even a single inferential step needed to link the regulated activity here to an impact on commerce. As the dissent frames the issue, there is no lack of nexus between the regulated activity and its effects on interstate commerce because they are one and the same! To the extent the dissent describes the conduct being regulated as the uncompensated consumption of health care services, the language of the mandate refers only to insurance and contains no reference to health care services, much less how health care services are consumed or paid for. The dissent can find no inferential leap because it has assumed away the very problem in this case, effectively treating the mandate as operating at the point of consumption. Under the dissent’s re-framing of the issue, the VAWA’s civil-remedy provision in Morrison could be regarded as regulating the “consumption of health care services,” because such consumption inevitably and empirically flows from gender-motivated violence. 147 79 Stat. 286 (1965) (establishing Medicare and Medicaid); Federal Food, Drug, and Cosmetic Act, Pub. L. No. 75-717, 52 Stat. 1040 (1938). It is clear that Congress has enacted comprehensive legislation regarding health insurance and health care. The Act is another such example. Yet, the narrow constitutional question here is whether one provision—§ 5000A—in that massive regulation goes too far. For the individual mandate to be sustained, it must be enacted pursuant to a valid exercise of Article I power. It simply will not suffice to say that, because Congress has regulated broadly in a field, it may regulate in any fashion it pleases. The Constitution supplies Congress with various tools to effectuate its legislative power, but it also denies others. In assessing Congress’s exercise of power, courts recognize that the structural limits embedded in the Constitution are of equal dignity to the express prohibitions—and may even be a more prevalent source of limitation. See, e.g., Comstock, 560 U.S. at __, 130 S. Ct. at 1968 (Kennedy, J., concurring) (rejecting notion that “the Constitution’s express prohibitions” are “the only, or even the principal, constraints on the exercise of congressional power” (emphasis added)).120 120 The Supreme Court reminds us that “the federal structure serves to grant and delimit the prerogatives and responsibilities of the States and the National Government vis-à-vis one another” and “action that exceeds the National Government’s enumerated powers undermines the sovereign interests of States.” Bond, 564 U.S. at __, __, 131 S. Ct. at 2364, 2366; see also 148 The Supreme Court’s Commerce Clause jurisprudence emphasizes that, in assessing the constitutionality of Congress’s exercise of its commerce authority, a relevant factor is whether a particular federal regulation trenches on an area of traditional state concern. See Morrison, 529 U.S. at 611, 613, 615–16, 120 S. Ct. at 1750–51, 1753; Lopez, 514 U.S. at 561 n.3, 564–68, 115 S. Ct. at 1631 n.3, 1632–34. The Supreme Court has expressed concern that “Congress might use the Commerce Clause to completely obliterate the Constitution’s distinction between national and local authority.” Morrison, 529 U.S. at 615, 120 S. Ct. at 1752; see also Raich, 545 U.S. at 35–36, 125 S. Ct. at 2216–17 (Scalia, J., concurring); Lopez, 514 U.S. at 557, 567–68, 115 S. Ct. at 1628–29, 1634; id. at 577, 115 S. Ct. at 1638–39 (Kennedy, J., concurring) (stating that if Congress were to assume control over areas of traditional state concern, “the boundaries between the spheres of federal and state authority would blur and political responsibility would become illusory. The resultant inability to hold either branch of the government answerable to the citizens is more dangerous even than devolving too much authority to the remote central power” (citation omitted)). Coupled with this Gregory, 501 U.S. at 458, 111 S. Ct. at 2399 (“This federalist structure of joint sovereigns preserves to the people numerous advantages. It assures a decentralized government that will be more sensitive to the diverse needs of a heterogenous society; it increases opportunity for citizen involvement in democratic processes; it allows for more innovation and experimentation in government; and it makes government more responsive by putting the States in competition for a mobile citizenry.”). 149 consideration, the Supreme Court recognizes that the Constitution “withhold[s] from Congress a plenary police power.” Lopez, 514 U.S. at 566, 115 S. Ct. at 1633; see also Morrison, 529 U.S. at 618–19, 120 S. Ct. at 1754; cf. Comstock, 560 U.S. at __, 130 S. Ct. at 1964; id. at __, 130 S. Ct. at 1967 (Kennedy, J., concurring) (stating that the police power “belongs to the States and the States alone”). In addition, whether the regulated subject matter is an area of traditional state concern impacts three of the five Comstock factors pertinent to a Necessary and Proper Clause analysis: (1) whether there is a long history of federal involvement in this arena, (2) whether the statute accommodates or supplants state interests, and (3) the statute’s narrow scope. 560 U.S. at __, 130 S. Ct. at 1965. With these principles in mind, we examine whether insurance and health care qualify as areas of traditional state concern. Prior to the Supreme Court’s 1944 decision in South-Eastern Underwriters, “the States enjoyed a virtually exclusive domain over the insurance industry.” St. Paul Fire & Marine Ins. Co. v. Barry, 438 U.S. 531, 539, 98 S. Ct. 2923, 2928 (1978). Thus, South-Eastern Underwriters was “widely perceived as a threat to state power to tax and regulate the insurance industry.” United States Dep’t of Treasury v. Fabe, 508 U.S. 491, 499–500, 113 S. Ct. 2202, 2207 (1993); see also Cantor v. Detroit Edison Co., 150 428 U.S. 579, 608 n.4, 96 S. Ct. 3110, 3126 n.4 (1976) (Blackmun, J., concurring) (“Congress’ expressed concern [was that the result in South-Eastern Underwriters] would ‘greatly impair or nullify the regulation of insurance by the States,’ bringing to a halt their ‘experimentation and investigation in the area.’”). “To allay those fears, Congress moved quickly to restore the supremacy of the States in the realm of insurance regulation.” Fabe, 508 U.S. at 500, 113 S. Ct. at 2207 (emphasis added). In 1945, a year after South-Eastern Underwriters, Congress passed the McCarran-Ferguson Act, 59 Stat. 33, ch. 20, 15 U.S.C. §§ 1011–1015.121 The McCarran-Ferguson Act preserved state regulatory control over insurance, which was largely considered by Congress to be a “local matter.” W. & S. Life Ins. Co. v. State Bd. of Equalization, 451 U.S. 648, 653, 101 S. Ct. 2070, 2075 (1981) (quoting H.R. Rep. No. 143, at 2 (1945)). The passage of the McCarran-Ferguson Act signaled Congress’s recognition of the states’ historical role in regulating insurance within their boundaries—and its unwillingness to supplant their vital function as a source of experimentation. Prudential Ins. Co. v. Benjamin, 328 U.S. 121 The McCarran-Ferguson Act states: (1) “[t]he business of insurance, and every person engaged therein, shall be subject to the laws of the several States which relate to the regulation or taxation of such business,” 15 U.S.C. § 1012(a), and (2) “[n]o Act of Congress shall be construed to invalidate, impair, or supersede any law enacted by any State for the purpose of regulating the business of insurance, or which imposes a fee or tax upon such business, unless such Act specifically relates to the business of insurance,” id. § 1012(b). 151 408, 429, 66 S. Ct. 1142, 1155 (1946) (“Obviously Congress’ purpose [in passing the McCarran-Ferguson Act] was broadly to give support to the existing and future state systems for regulating and taxing the business of insurance.”); see also Ne. Bancorp, Inc. v. Bd. of Governors of Fed. Reserve Sys., 472 U.S. 159, 179, 105 S. Ct. 2545, 2556 (1985) (O’Connor, J., concurring) (“The business of insurance is also of uniquely local concern . . . . [and] historically ha[s] been regulated by the States in recognition of the critical part [it] play[s] in securing the financial well-being of local citizens and businesses.” (citations omitted)). Our Circuit has reached a similar conclusion. Blue Cross & Blue Shield v. Nielsen, 116 F.3d 1406, 1413 (11th Cir. 1997) (“Adjustment of the rights and interests of insurers, health care providers, and insureds is a subject matter that falls squarely within the zone of traditional state regulatory concerns.”). Thus, insurance qualifies as an area of traditional state regulation. This recognition counsels caution, and supplies reviewing courts with even greater cause for doubt when faced with an unprecedented economic mandate of dubious constitutional status. Cf. Lopez, 514 U.S. at 583, 115 S. Ct. at 1641 (Kennedy, J., concurring) (“The statute now before us forecloses the States from experimenting and exercising their own judgment in an area to which States lay claim by right of history and expertise, and it does so by regulating an activity beyond the realm of 152 commerce in the ordinary and usual sense of that term.”). The health care industry also falls within the sphere of traditional state regulation. A state’s role in safeguarding the health of its citizens is a quintessential component of its sovereign powers. The Supreme Court has declared that the “structure and limitations of federalism . . . allow the States great latitude under their police powers to legislate as to the protection of the lives, limbs, health, comfort, and quiet of all persons.” Gonzales v. Oregon, 546 U.S. 243, 270, 126 S. Ct. 904, 923 (2006) (quotation marks and citation omitted). Numerous Supreme Court decisions have identified the regulation of health matters as a core facet of a state’s police powers. See, e.g., Hill v. Colorado, 530 U.S. 703, 715, 120 S. Ct. 2480, 2489 (2000) (“It is a traditional exercise of the States’ police powers to protect the health and safety of their citizens.” (quotation marks and citation omitted)); Barnes v. Glen Theatre, Inc., 501 U.S. 560, 569, 111 S. Ct. 2456, 2462 (1991) (“The traditional police power of the States is defined as the authority to provide for the public health, safety, and morals.”); Head v. N.M. Bd. of Exam’rs in Optometry, 374 U.S. 424, 428, 83 S. Ct. 1759, 1762 (1963) (“[T]he statute here involved is a measure directly addressed to protection of the public health, and the statute thus falls within the most traditional concept of what is compendiously known as the police power.”); Barsky v. Bd. of Regents, 347 153 U.S. 442, 449, 74 S. Ct. 650, 654 (1954) (“It is elemental that a state has broad power to establish and enforce standards of conduct within its borders relative to the health of everyone there. It is a vital part of a state’s police power.”); Jacobson v. Massachusetts, 197 U.S. 11, 25, 25 S. Ct. 358, 360 (1905) (“According to settled principles, the police power of a state must be held to embrace, at least, such reasonable regulations established directly by legislative enactment as will protect the public health and the public safety.”); see also Raich, 545 U.S. at 42, 125 S. Ct. at 2221 (O’Connor, J., dissenting) (“This case exemplifies the role of States as laboratories. The States’ core police powers have always included authority to define criminal law and to protect the health, safety, and welfare of their citizens.”).122 Although the states and the federal government both play indispensable roles in regulating matters of health, modern Supreme Court precedents have confirmed the view that the health of a state’s citizens is predominantly a statebased concern: “the regulation of health and safety matters is primarily, and historically, a matter of local concern.” Hillsborough Cnty. v. Automated Med. 122 Gibbons, which represents one of the Supreme Court’s earliest articulations of the states’ reserved police powers, also provides insight into the traditionally local nature of health laws. In Gibbons, Chief Justice Marshall remarked that “[i]nspection laws, quarantine laws, health laws of every description, as well as laws for regulating the internal commerce of a State” together “form a portion of that immense mass of legislation, which embraces every thing within the territory of a State, not surrendered to the general government: all which can be most advantageously exercised by the States themselves.” 22 U.S. at 203 (emphasis added). 154 Labs., Inc., 471 U.S. 707, 719, 105 S. Ct. 2371, 2378 (1985). The Supreme Court similarly has stated that the narrower category of “health care” is an area of traditional state concern. See, e.g., Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355, 387, 122 S. Ct. 2151, 2171 (2002) (referring to “‘the field of health care’” as “‘a subject of traditional state regulation’” (quoting Pegram v. Herdrich, 530 U.S. 211, 237, 120 S. Ct. 2143, 2158 (2000))); N.Y. State Conf. of Blue Cross & Blue Shield Plans v. Travelers Ins. Co., 514 U.S. 645, 661, 115 S. Ct. 1671, 1680 (1995) (“[G]eneral health care regulation . . . historically has been a matter of local concern.”). Here, it is undisputed that the individual mandate supersedes a multitude of the states’ policy choices in these key areas of traditional state concern. Congress’s encroachment upon these areas of traditional state concern is yet another factor that weighs in the plaintiffs’ favor, and strengthens the inference that the individual mandate exceeds constitutional boundaries. The inference is particularly compelling here, where Congress has used an economic mandate to compel Americans to purchase and continuously maintain insurance from a private company. We recognize the argument that, if states can issue economic mandates, Congress should be able to do so as well. Yes, some states have exercised their 155 general police power to require their citizens to buy certain products—most pertinently, for our purposes, health insurance itself.123 But if anything, this gives us greater constitutional concern, not less. Indeed, if the federal government possesses the asserted power to compel individuals to purchase insurance from a private company forever, it may impose such a mandate on individuals in states that have elected not to employ their police power in this manner.124 After all, if and when Congress actually operates within its enumerated commerce power, Congress, by virtue of the Supremacy Clause, may ultimately supplant the states. When this occurs, a state is no longer permitted to tailor its policymaking goals to the specific needs of its citizenry. This is precisely why it is critical that courts preserve constitutional boundaries and ensure that Congress only operates within the proper scope of its enumerated commerce power. In sum, the fact that Congress has enacted this insurance mandate in an area 123 See, e.g., MASS. GEN . LAWS ch. 111M § 2 (Massachusetts law requiring residents 18 years and older to “obtain and maintain creditable coverage so long as it is deemed affordable”); N.J. STAT . ANN . § 26:15-2 (New Jersey law requiring residents 18 years and younger to “obtain and maintain health care coverage that provides hospital and medical benefits”). 124 Some states have even passed legislation providing that their citizens may not be required to obtain or maintain health insurance. See, e.g., Utah Code Ann. § 63M-1-2505.5; Va. Code Ann. § 38.2-3430.1:1; see also ARIZ. CONST . Art. XXVII, § 2 (“A law or rule shall not compel, directly or indirectly, any person, employer or health care provider to participate in any health care system.”). The American Legislative Exchange Council, a nonprofit membership association of state legislators, filed a helpful amicus brief documenting the diverse array of policies implemented by states to provide their citizens with health coverage. See Br. of Amicus Curiae American Legislative Exchange Council in Support of Plaintiffs at 21–28. 156 of traditional state concern is a factor that strengthens the inference of a constitutional violation. When this federalism factor is added to the numerous indicia of constitutional infirmity delineated above, we must conclude that the individual mandate cannot be sustained as a valid exercise of Congress’s power to regulate activities that substantially affect interstate commerce. We do not reach this conclusion lightly, and we recognize that “[d]ue 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.” Morrison, 529 U.S. at 607, 120 S. Ct. at 1748. But we believe a compelling showing has been made here, and “the federal balance is too essential a part of our constitutional structure and plays too vital a role in securing freedom for us to admit inability to intervene when one or the other level of Government has tipped the scales too far.” Lopez, 514 U.S. at 578, 115 S. Ct. at 1639 (Kennedy, J., concurring) (citations omitted).