The Supreme Court on Thursday upheld the individual insurance requirement at the heart of President Barack Obama's historic health care overhaul -- impacting more than 6 million uninsured Texans that will have to pay for health insurance or pay a fine in the form of a tax.
The mandate was upheld under the federal government's power to levy taxes.
The Affordable Care Act aims to cover more than 30 million uninsured Americans, including 1 out of every 4 Texans. As of 2009, Texas has the highest uninsured rate in the country at 26.1 percent.
In a state with one of the lowest unemployment rates in the nation, the high number of those without insurance may seem surprising. But, according to the Center for Public Policy Priorities' Texas Health Care Primer, many employers do not provide insurance for their employees for the same reason many people don't purchase insurance -- the high cost of coverage.
According to the primer, almost two-thirds of employed, working Texans have no health insurance. Among working-age Texans between the ages of 19 and 64, the primary source of coverage is employment-based and covers 52 percent of those adults. Because Medicaid and Medicare coverage for working-age adults is low, Texans in that age range are most likely to be uninsured.
With the Supreme Court's decision on Thursday, virtually all uninsured Americans would have to pay for health insurance or pay a penalty tax.
Texas Attorney General Greg Abbott is expected to issue a statement on the ruling at noon. President Obama is expected to speak from the White House at 11:15 a.m.
A recent NBC News/WSJ poll found more Americans said they would be pleased if the law was ruled unconstitutional than constitutional. Read other opinions on the ruling from around the state of Texas here and from other national sources here.
Where Texas Stands
Texas has not implemented an online health insurance marketplace. But the Texas Health and Human Services Commission, which oversees Medicaid in the state, says the agency already has met deadlines for some requirements, such as implementing a tobacco cessation benefit for pregnant women on Medicaid. In addition, at least 5,700 Texans are participating in a federally mandated insurance plan for those with pre-existing conditions, though the U.S. Department of Health and Human Services is running that program instead of Texas.
Chief Justice john Roberts wrote the decision in the 5-4 ruling, but as it stands now there is no penalty for not paying the penalty tax.
Breaking with the court's other conservative justices, Roberts announced the judgment that allows the law to go forward. The justices rejected two of the administration's three arguments in support of the insurance requirement. But the court said the mandate can be construed as a tax.
"Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness," Roberts said.
The decision means the huge overhaul, still only partly in effect, will proceed and pick up momentum over the next several years, affecting the way that countless Americans receive and pay for their personal medical care. The ruling also hands Obama a campaign-season victory in rejecting arguments that Congress went too far in requiring most Americans to have health insurance or pay a penalty.
The ruling put some limits on the law's plan to expand the Medicaid insurance program for the poor, a joint effort of the federal government and states. It says the U.S. government cannot threaten to withhold a state's entire Medicaid allotment if it doesn't participate in the expansion.
The court's four liberal justices, Stephen Breyer, Ruth Bader Ginsburg, Elena Kagan and Sonia Sotomayor, joined Roberts in the outcome. Justices Samuel Alito, Anthony Kennedy, Antonin Scalia and Clarence Thomas dissented.
"The act before us here exceeds federal power both in mandating the purchase of health insurance and in denying non-consenting states all Medicaid funding," the dissenters said in a joint statement.
The decision affects nearly every American and marks a major milepost in a century of efforts to make health care available to all. The law is President Barack Obama's signature legislative achievement and perhaps the most polarizing issue of his re-election campaign. His Republican rival Mitt Romney and GOP lawmakers have promised to repeal Obamacare.
The 2010 health care law will continue phasing in as planned. It's expected to bring coverage to about 30 million uninsured people, so that more than 9 in 10 eligible Americans will be covered.
Some parts are already in effect: Young adults can stay on their parents' insurance up to age 26. Insurers can't deny coverage to children with health problems. Limits on how much policies will pay out to each person over a lifetime are eliminated. Hundreds of older people already are saving money through improved Medicare prescription benefits. And co-payments for preventive care for all ages have been eliminated.
What is Next?
Starting in 2014, almost everyone will be required to be insured or pay a fine. There are subsidies to help people who can't afford coverage. Most employers will face fines if they don't offer coverage for their workers. Newly created insurance markets will make it easier for individuals and small businesses to buy affordable coverage. And Medicaid will be expanded to cover more low-income people.
Insurers will be prohibited from denying coverage to people with medical problems or charging those people more. They won't be able to charge women more, either. During the transition to 2014, a special program for people with pre-existing health problems helps these people get coverage.
An assortment of tax increases, health industry fees and Medicare cuts will help pay for the changes.
Is the Issue Settled Now?
Not necessarily. Although the court found it constitutional, the health care law still could be changed by Congress. Romney and Republican congressional candidates are campaigning on promises to repeal it if elected in November.
Some parts of the law are popular, but others -- especially the mandate that virtually everyone have insurance coverage -- are not.
Also, an estimated 26 million people will remain without health coverage once the law is fully implemented, including illegal immigrants, people who don't sign up and elect to face the fine instead, and those who can't afford it even with the subsidies.
Mark Sherman and Connie Cass with The Associated Press contributed to this report.