On January 31, 2011, a fourth federal district court ruled on the constitutionality of the Patient Protection and Affordable Care Act (PPACA or the Act). See Bondi, et al., v. U.S. Dept. of Health & Human Services, Case No.: 3:10-cv-91-RV/EMT (N.D. Fla. 2011). The court addressed two questions: (1) whether the Act’s expansion of the Medicaid program to include a larger eligible population violated the Spending Clause of the Constitution and principles of federalism protected by the Ninth and Tenth Amendments (the “Medicaid expansion issue”); and (2) whether the mandate that all individuals purchase health insurance by 2014 or pay a penalty violates the Commerce Clause of the Constitution (the “individual mandate issue”). With respect to the Medicaid expansion issue, the Court ruled that because state participation in the Medicaid Program “is--as it has always been--voluntary,” the provisions of PPACA expanding Medicaid coverage are not unconstitutional. With respect to the second issue, however, the court found that because the Commerce Clause does not extend the power to Congress to regulate “inactivity” (i.e., the failure to purchase health insurance), the individual mandate is unconstitutional. This ruling is consistent with the ruling issued in the Eastern District of Virginia, but contrary to decisions issued by the Western District of Virginia and the Eastern District of Michigan, which both upheld the Act in its entirety. However, the Bondi decision took its ruling one step further than the Eastern Virginia district court, finding that because the individual mandate is “inextricably bound together in purpose” with the other provisions of the Act, it cannot be severed, and the entire Act is therefore unconstitutional. However, the court's boldness ended with its declaration of the Act's unconstitutionality; it refused to issue an injunction against the Act’s continued implementation, prompting confusion as to the practical effect of the ruling.

The Bondi case involved 26 states: Alabama, Alaska, Arizona, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Ohio, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Washington, Wisconsin, and Wyoming. In the decision’s aftermath, state officials in at least Florida, Idaho, and Wisconsin have made public statements regarding their belief that the ruling permits them to abandon further implementation of PPACA immediately. See Amy Goldstein and N.C. Aizenman, “States Divided on Meaning of Health Care Ruling,” (Washington Post), January 26, 2011, available online at CBS News. On the other hand, officials in Georgia, Iowa, and Mississippi have indicated that preparations for the Act’s implementation will continue while the legal challenges inevitably proceed to the Supreme Court, because to cease preparations while awaiting a final ruling would be “irresponsible,” and leave the states too far behind in the event that the Supreme Court finds the Act to be constitutional. The federal government is currently considering whether it is necessary to seek a stay from a higher court, ordering the continued implementation of PPACA while the legal challenges proceed to the Supreme Court.