The U.S. Constitution does not support a provision of the landmark health care law passed this year that would require most people to get health insurance, according to a Monday ruling by a federal judge in Virginia.

Lack of health insurance leads to 44,789 excess deaths in the U.S. each year, a 2009 study estimated. And annual medical costs that go unpaid added up to about $43 billion in 2005, according to a study published that year.

The ruling is the first to overturn the Patient Protection and Affordable Care Act, which was signed into law in March.

Henry E. Hudson, the U.S. District judge in Richmond who made the ruling, wrote that the health care law violates the Tenth Amendment of the Constitution, which states that anything not specifically designated for federal control is "reserved to the States respectively, or to the people." Health care—and more specifically the decision to purchase health insurance, known as the Minimum Essential Coverage Provision—falls under that clause and thus new federal rules are "in direct conflict" with the 2010 Virginia Health Care Freedom Act, Hudson concluded in his decision [pdf].

Many of those who support the health care law's insurance provision point to the increased use of primary and preventive care among people who have affordable health insurance. And many studies have pointed to primary care as a way to overcome key disparities in health care—as well as reduce ballooning medical costs over the coming years.

Some 20 states are involved in a separate lawsuit currently pending in Florida, the Richmond Times-Dispatch reported. And two other U.S. District cases—from Michigan and previously from Lynchburg, Va.—have sided with the federal government's right to require most Americans to obtain health insurance or face a penalty, NPR noted.

The case ruled upon Monday was brought against the government by Virginia Republican Attorney General Kenneth Cuccinelli. Hudson noted in his decision that the government's case "holds the weaker hand." He emphasized, however, he is not opining on "the wisdom of Congress or the public policy implications of the [Affordable Care Act]," but rather "solely on the constitutionality of the enactment." He declined a request for an injunction that would further halt the Act's implementation.

The issue is expected to wind up in the U.S. Supreme Court in the next couple years, The New York Times reported. The ruling is not expected to have an immediate effect on the Affordable Care Act, as many of the provisions are not set to take effect until 2014. Nevertheless, "you might see some air taken out of the balloon nationwide," Jason Helgerson, the Medicaid director in Wisconsin, told the Times about the push for broader health insurance coverage.

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