The Supreme Court ruled that the individual mandate of the Affordable Care Act exceeded the scope of the Commerce Clause and the Necessary and Proper Clause, but it could be upheld as a tax under Congress's taxing power. However, any tax imposed by Congress must comply with other constitutional requirements, such as the apportionment of direct taxes among the states based on population. The Court found that the shared responsibility payment required under the ACA qualified as a tax. The Court also held that Congress had the power to condition federal funds to the States on compliance with specific conditions, including the Medicaid expansion. However, the Court found that the Medicaid expansion under the Affordable Care Act was impermissibly coercive, as the threat of losing all Medicaid funding was a gun to the head rather than a relatively mild encouragement.

The passage addresses the constitutionality of the Affordable Care Act's minimum coverage provision and Medicaid expansion. Justice Ginsburg asserts that Congress has the authority to implement a federal healthcare system, and the minimum coverage provision is valid under the Congress' tax power. To encourage people to obtain insurance, the provision imposes a tax penalty on those who do not. This approach is practical and reasonable, providing a solution to reduce the number of uninsured individuals. According to the Commerce Clause, Congress has the power to regulate commerce among the several States, and the minimum coverage provision is an essential exercise of this power. The passage also favors the individual mandate provision of the ACA and opposes the activity versus inactivity debate, citing case law. The Supreme Court has upheld that the minimum coverage provision of the ACA is a proper exercise of Congress' power to tax and spend for the general welfare of the United States.

The Supreme Court ruled that the Individual Mandate in the Affordable Care Act is invalid as it creates commerce rather than regulating it. The minimum coverage provision is a mandate with a penalty attached, not a tax. The Court is examining the constitutionality of the Medicaid program's expansion and the Federal Government's power to attach conditions to grants given to states. The anticoercion principle is crucial in determining whether the conditions attached to federal grants to the States are legitimate. The ACA's Medicaid Expansion offer is not as generous as claimed by the Federal Government, and Congress' threat to cut off all Medicaid funds is considered coercive and raises questions about the constitutionality of the offer. The Individual Mandate and Medicaid Expansion are invalid, and all other provisions of the Act must fall as well.

Justice Thomas dissents from the majority opinion, stating that the Individual Mandate exceeds Congress' power under the Commerce Clause and the Necessary and Proper Clause. He argues that the "substantial effects" test is inconsistent with the original understanding of Congress' powers and has led to an overreach of the Federal Government's authority. He notes that the Government's claim that it can regulate inactivity that affects interstate commerce is unprecedented.