President Obama's health care law isn't out of the legal woods yet.
Six months after surviving the Supreme Court on a 5-4 vote, the law still faces lower-court challenges to its insurance-purchasing mandates, tax penalties, Medicare cost controls, benefit packages and more.
The cases pose less of a threat to the law than the challenges mounted by 26 states and business groups last spring, but the justices' ruling to uphold the law on narrow grounds indicated festering opposition inside and outside the court. That makes a return trip to the high court a possibility in the future.
The latest indication came last month, when the court gave new life to a lawsuit filed by Liberty University in Virginia, a religious institution that objected to the employer and individual mandates for purchasing insurance. The school is one of many religious organizations that object to the inclusion of birth control among the benefits that must be covered.
About 40 lawsuits are challenging the contraception mandate on religious grounds. They come mostly from church-affiliated schools and hospitals opposed to abortion. While the Obama administration in February sought to exempt faith-based groups from having to provide the coverage directly, self-insured employers say they have little choice.
"This is a pressing question that needs to be addressed," says Mathew Staver, dean of the Liberty University School of Law. "It will be a historic clash between the free exercise of religion and a federal law."
Victory on that count could free religious groups that object to covering contraceptives from the law's minimum coverage requirement. The heart of the law -- expanding affordable health coverage to millions of Americans and requiring most individuals and large employers to buy insurance -- would stand.
Lawsuits that could threaten the entire law haven't advanced as far. Experts say they have less chance of reaching the Supreme Court and toppling Obama's signature domestic policy achievement.
"The tough challenges to the statute have been litigated already," says Robert Weiner, a former associate deputy attorney general who led the administration's defense of the health care law. "The remaining ones are the leftovers."
Among the cases:
The Goldwater Institute, a conservative research and legal advocacy organization in Arizona, claims that the law's Independent Payment Advisory Board violates the Constitution's separation of powers clause.
The appointed board, which is designed to hold down Medicare costs, is not subject to congressional oversight or even "meaningful agency review," says Christina Sandefur, a lawyer with the institute.
The institute also contends that to avoid a tax penalty, individuals have to disclose medical information to insurers and the federal government. That represents an undue burden on liberty and privacy, Sandefur says.
A lawsuit filed by the Pacific Legal Foundation, another conservative advocacy group, notes that the law only survived the Supreme Court because Chief Justice John Roberts said its penalties for not buying insurance were taxes.
The health care law was written in the Senate, but with a twist. Lawmakers took a House bill, stripped it of its title and all its provisions, and substituted the health care law. Tax laws, the group notes, must originate in the House, not the Senate.
If federal courts buy that argument, foundation attorney Paul Beard says, "I think the whole thing would have to fall."
Oklahoma is challenging the law's implementation. States that won't create their own health insurance exchanges, or markets, should not fall under a provision that subjects employers of 50 or more to penalties if they don't offer insurance, Attorney General Scott Pruitt says.
The IRS ruled otherwise in May, even though the health care law specified only that states with their own insurance exchanges would be subject to the employer penalties. Pruitt says that's illegal unless Congress amends the law.
"I think people are for the first time saying, 'Wow, you mean there's a tax that's going to be assessed against employers?'" Pruitt says.
The Obama administration, while monitoring the lawsuits, is focused on getting insurance purchasing exchanges created and expanding Medicaid coverage in the states.
"The Supreme Court has ruled, and the Affordable Care Act is the law of the land," White House spokesman Nick Papas says. "We remain 100% focused on implementing the law and are confident these remaining cases will be resolved in our favor."
The legal wrangling won't go away soon. Randy Barnett, a Georgetown University law professor whose contention that the health care law was unconstitutional led to the original Supreme Court challenge, likens the bevy of new lawsuits to the idiom "in for a penny, in for a pound."
"I always thought that if you didn't take out the whole Affordable Care Act, there was then going to be legal issues having to do with parts of it," Barnett says. "Now the courts are in for a pound."
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