(CNN) Adapted from " The Chief: The Life and Turbulent Times of Chief Justice John Roberts " by Joan Biskupic. Copyright © 2019. Available from Basic Books. Chief Justice John Roberts arrived at the Valletta campus of the University of Malta on July 3, 2012, to teach a class on Supreme Court history. As he emerged from the back seat of a black sedan, he held his brown leather briefcase in front of him, almost as a shield. He wore a blue blazer, striped button-down shirt, and tan khakis. His clothes looked crisp, though his face was haggard. He was as exhausted and distressed as he had been in years. Roberts had left behind a storm in Washington over his opinion upholding President Barack Obama's health-care overhaul -- the Affordable Care Act -- a stunning validation of Obama's signature domestic achievement that transformed public perceptions of the chief justice. Republicans in Congress had been fighting the law dubbed Obamacare at every turn for two years, and all the GOP presidential candidates in 2012 had vowed to repeal it. And now Roberts, a nominee of President George W. Bush, had saved it. Going forward, the chief justice would be viewed with skepticism by conservatives, despite also having taken the lead on limiting racial remedies and voting rights, helping roll back campaign finance regulations and voting for stronger Second Amendment gun rights. Roberts' moves behind the scenes were as extraordinary as his ruling. He changed course multiple times. He was part of the majority of justices who initially voted in a private conference to strike down the individual insurance mandate -- the heart of the law -- but he also voted to uphold an expansion of Medicaid for people near the poverty line. Two months later, Roberts had shifted on both. The ACA, signed by Obama in 2010, followed decades of failed attempts in Washington to control spiraling medical costs and provide Americans with higher-quality health care. It created a marketplace where the uninsured could buy coverage and protected people from being unable to get health insurance because of pre-existing conditions such as diabetes, cancer and other chronic illnesses. To support the system and draw in the healthy as well as the sick, the law required that most uninsured people obtain coverage (the "individual mandate") or pay a penalty, to be collected as part of an individual's annual taxes -- a provision critical to the final ruling. The law also expanded Medicaid benefits to a wider range of needy individuals. The money for about 90% of that expansion would come from the federal government. But it would come with a strict condition: If states did not broaden their programs as dictated they would lose all Medicaid funds. The first meeting -- 5-4 against the mandate After an unusual three full days of oral arguments in late March 2012 (a typical case gets one hour on one day), the nine justices gathered in a private conference room off the chief's chambers to cast initial votes. They were alone, with no law clerks or administrative staff. The discussion focused on the individual insurance mandate and Congress' power to regulate commerce. Roberts went first, as was the custom, laying out his views. He emphasized that he believed the Constitution's commerce clause never was intended to cover inactivity, such as the refusal to buy insurance. After the chief, conservative Justices Antonin Scalia, Anthony Kennedy and Clarence Thomas offered their views. Like Roberts, they thought Congress' commerce authority did not cover an individual's decision to forgo -- rather than obtain -- health insurance. There were thus four immediate votes cast to invalidate the mandate. No one at the table was surprised, based on the questions during oral arguments and word from law clerks inside the building circulating intelligence among the justices' chambers. Photos: Chief Justice John Roberts Supreme Court Chief Justice John Roberts listens to President Donald Trump's State of the Union address in January 2018. Hide Caption 1 of 22 Photos: Chief Justice John Roberts Roberts is seen in a yearbook photo from his prep school in La Porte, Indiana. He was born in Buffalo but grew up in northwest Indiana. In 1979, he graduated from Harvard Law School. Hide Caption 2 of 22 Photos: Chief Justice John Roberts Roberts shakes hands with US President Ronald Reagan in 1983. He was an associate counsel to Reagan from 1982-1986. Hide Caption 3 of 22 Photos: Chief Justice John Roberts As an attorney for the government and in 14 years of private practice, Roberts argued 39 cases before the Supreme Court and won 25 of them. Hide Caption 4 of 22 Photos: Chief Justice John Roberts In May 2001, President George W. Bush nominated Roberts to the US Court of Appeals for the District of Columbia. Roberts is seen at right along with Bush's other judicial appointments. Hide Caption 5 of 22 Photos: Chief Justice John Roberts In 2005, Bush nominated Roberts to replace retiring Supreme Court Justice Sandra Day O'Connor. Hide Caption 6 of 22 Photos: Chief Justice John Roberts Roberts, third from left, meets with US senators in Washington a day after he was nominated by Bush. With Roberts, from left, are Sens. Arlen Specter, Bill Frist and Mitch McConnell. Hide Caption 7 of 22 Photos: Chief Justice John Roberts Roberts meets with US Sen. Mary Landrieu as he makes his rounds on Capitol Hill in July 2005. Hide Caption 8 of 22 Photos: Chief Justice John Roberts Roberts was tabbed to replace O'Connor, but plans changed after Chief Justice William Rehnquist died in September 2005. Bush announced that he wanted Roberts to replace Rehnquist instead. Hide Caption 9 of 22 Photos: Chief Justice John Roberts O'Connor weeps as Roberts and other pallbearers carry Rehnquist's casket into the Supreme Court. Roberts was once a law clerk for Rehnquist. Hide Caption 10 of 22 Photos: Chief Justice John Roberts Roberts answers questions during his second day of confirmation hearings in September 2005. The Senate voted 78-22 to confirm him. Hide Caption 11 of 22 Photos: Chief Justice John Roberts Roberts' wife, Jane, holds a Bible as her husband is sworn in by Supreme Court Justice John Paul Stevens. Hide Caption 12 of 22 Photos: Chief Justice John Roberts Roberts and his wife attend his swearing-in ceremony in the East Room of the White House. Hide Caption 13 of 22 Photos: Chief Justice John Roberts The Roberts walk with their children, Jake and Josie, after he took the Supreme Court bench for the first time in October 2005. Hide Caption 14 of 22 Photos: Chief Justice John Roberts Bush enjoys a light moment with Roberts and other Supreme Court justices on Roberts' first day. With Bush, from left, are John Paul Stevens, Ruth Bader Ginsburg, David Souter, Antonin Scalia, Roberts, O'Connor and Kennedy. Hide Caption 15 of 22 Photos: Chief Justice John Roberts Roberts shakes hands with President Barack Obama at Obama's inauguration ceremony in 2009. Hide Caption 16 of 22 Photos: Chief Justice John Roberts Roberts watches Elena Kagan sign the Oaths of Office after she replaced retiring Justice John Paul Stevens in 2010. Hide Caption 17 of 22 Photos: Chief Justice John Roberts Roberts administers the oath of office to President Donald Trump in 2017. Hide Caption 18 of 22 Photos: Chief Justice John Roberts The US Supreme Court, with newest member Brett Kavanaugh, poses for an official portrait in November 2018. In the back row, from left, are Neil Gorsuch, Sonia Sotomayor, Kagan and Kavanaugh. In the front row, from left, are Stephen Breyer, Clarence Thomas, Roberts, Ginsburg and Samuel Alito. Hide Caption 19 of 22 Photos: Chief Justice John Roberts Roberts and Thomas pay their respects to the late President George H.W. Bush as he lies in state in December 2018. Hide Caption 20 of 22 Photos: Chief Justice John Roberts Roberts arrives at the US Capitol to preside over President Trump's impeachment trial in February 2020. Hide Caption 21 of 22 Photos: Chief Justice John Roberts Roberts ends the impeachment trial after Trump was acquitted. Hide Caption 22 of 22 The votes of the liberals were known, too.<doc-sep>Smart content. Deeper culture. Better access. Become a subscriber to the Washington Examiner magazine. SIGN UP! If you’d like to continue receiving Washington Examiner's Daily on Healthcare newsletter, SUBSCRIBE HERE: http://newsletters.washingtonexaminer.com/newsletter/daily-on-healthcare/ ROBERTS FLIPPED ON OBAMACARE’S MEDICAID EXPANSION: Chief Justice John Roberts initially sided with the four liberal justices to support the part of Obamacare that obligated states to accept the Medicaid expansion or otherwise lose out on the program entirely, according an adapted excerpt from the book “Chief” out Tuesday by CNN's Joan Biskupic. The 2012 ruling in National Federation of Independent Business v. Sebelius to make the Medicaid provision in Obamacare optional ultimately landed at 7-2 as Roberts negotiated with Justices Elena Kagan and Stephen Breyer to side with the conservative justices in exchange for his vote to uphold the individual mandate. The justices thought that states would go along with the Medicaid expansion because the federal government covers the majority of costs. That assumption turned out to be incorrect. More than a dozen states still haven’t expanded, and Republican state legislatures all over the country are advancing laws to scale back expansion. Supreme Court deliberations are private, and justices don’t respond to rumors that surface or to reporting. It’s difficult to assess the claims in the book because the inner workings of the Supreme Court are closely guarded, and justices do not tend to share what goes on during their conferences where they discuss cases and cast voters. Clerks, too, are notoriously tight-lipped and take a vow of confidentiality. Jan Crawford had previously reported for CBS that Roberts initially believed the fine on the uninsured should be struck down, but the latest details from Biskupic on Medicaid are new. Roberts did not endorse the argument that the penalty could be upheld as an exercise of Congress’s power to regulate interstate commerce, but he did uphold it as allowed under the power to tax. In “Chief,” Biskupic reports that Roberts believed the individual mandate was only necessary to uphold Obamacare’s protections on pre-existing illnesses, but that without it the rest of the law could remain intact. His conservative colleagues disagreed and would not budge on their stance that the entire law would otherwise fall apart without it. Roberts unsuccessfully tried to convince Justice Anthony Kennedy, the notorious swing vote, not to support striking down the entire law, before instead turning to Kagan and Breyer. Roberts “acknowledged being torn between his heart and his head, as he put it, and express some hesitancy to strike down a law intended to solve the nation’s health insurance crisis,” Biskupic writes. The individual mandate ultimately was upheld 5-4. It was zeroed out this year as part of the tax law signed by President Trump, and is now facing additional legal challenges from Republican state officials who say it is an essential part of the law. The Trump administration believes it is only essential to the protections for people with pre-existing illnesses, as Roberts also believed, according to Biskupic’s reporting. Good morning and welcome to the Washington Examiner’s Daily on Healthcare! This newsletter is written by senior healthcare reporter Kimberly Leonard (@LeonardKL) and healthcare reporter Cassidy Morrison (@CassMorrison94). You can reach us with tips, calendar items, or suggestions at dailyonhealthcare@washingtonexaminer.com. If someone forwarded you this email and you’d like to receive it regularly, you can subscribe here. ALL FIVE INVITED PBMS AGREE TO TESTIFY BEFORE SENATE: Executives from CVS Caremark and CVS Health Corporation, OptumRx, Cigna Corporation, Prime Therapeutics LLC, and Humana have all agreed to testify on drug prices before the Senate Finance Committee on April 9. SOUTHERN, LESS POPULATED AREAS HAVE LEAST ACA COMPETITION: Southern areas of the U.S. with lower populations disproportionately make up the 322 regions with the least insurer competition, according to an analysis out Thursday by the left-leaning Urban Institute and funded by the Robert Wood Johnson Foundation. In the South, only 4 percent of residents have five or more insurers, and they typically face higher premiums. In general, the Obamacare marketplaces became more competitive for 2019. The share of people living in areas with five or more insurers increased from 18.6 to 20.1 percent, and the number of people living in the least competitive areas, of two or fewer insurers, decreased from 45.1 percent to 37.5 percent of the population. MARYLAND SENATE APPROVES ENROLLMENT PLAN: The Maryland state Senate on Thursday unanimously approved a plan that would steer residents toward health insurance plans, either through the Obamacare exchange or by auto-enrolling them in Medicaid, if they check a box on their state tax return saying they lack insurance. Residents could alternatively check a box saying they prefer to remain uninsured. The plan passed the Maryland House of delegates last week. MISSISSIPPI GOVERNOR SIGNS ABORTION BAN: Republican Gov. Phil Bryant has signed a bill into law that bans abortion when a heartbeat can be detected in a pregnancy, or somewhere between six and eight weeks, before many women know they are pregnant. Mississippi is one of 15 states that has introduced such bans. The state is already facing a lawsuit over a 15-week abortion ban it passed last year. EVERS WITHDRAWS WISCONSIN FROM ACA LAWSUIT: Democratic Gov. Tony Evers is pulling Wisconsin out of a multistate lawsuit challenging the Affordable Care Act after a judge blocked lame-duck laws Republicans passed in December that prohibited him from withdrawing from lawsuits without legislative approval. Circuit Court Judge Richard Niess blocked the GOP-passed laws in a Thursday injunction, ruling that the Legislature had convened illegally when it passed them. TEXTING-WHILE-DRIVING BANS LEAD TO FEWER ER VISITS: STUDY: In a study conducted of 16 states, those with blanket bans on texting while driving saw a 4 percent decrease in ER visits due to car accidents. The study concludes that states with distracted driving laws in place see an average of 1,632 fewer ER visits due to car accidents. CUMMINGS, DESAULNIER WRITE TO SACKLER FAMILY ABOUT ITS ROLE IN THE OPIOID EPIDEMIC: Rep. Elijah E. Cummings, D-Md. and Rep. Mark DeSaulnier, D-Calif. asked Purdue Pharma Craig Landau CEO Thursday for information about the Sackler family’s role in marketing OxyContin and other addictive painkillers in 1996. The letter suggests that the family, which owns a controlling share of the company, knew about OxyContin’s addictive qualities immediately after its release. They also reference a report that says the FDA buckled under Big Pharma pressure to label OxyContin suitable for "daily, around-the-clock, long-term… treatment” without scientific evidence. DRUG PRICING GROUP LASHES OUT AT PHARMA IN NEW AD: Patients For Affordable Drugs Now, which advocates for legislation to lower prescription drug prices, released a digital ad Thursday in support of the Trump administration’s proposal to adopt an International Pricing Index, which would tie the prices of drugs administered in a doctor’s office or hospital to that of other countries. Drug companies have objected to the plan, arguing that it would stifle innovation and patients’ access to healthcare. Patients For Affordable Drugs rebutted the arguments in its latest ad . NO MATERNAL DEATHS FOUND IN PRISON STUDY: A first-of-its-kind study published in the American Journal of Public Health suggests that maternal deaths for incarcerated women may be low. The study tracked pregnant women in 22 states and federal prisons over the course of two years and reported that none died from pregnancy or childbirth-related causes. Of the 1,396 pregnancies tracked, 46 ended in miscarriages, 11 ended in abortions, four ended in stillbirth and three newborns died. FINANCE COMMITTEE PROBES DOCTOR DISCLOSURES: Senate Finance Committee leaders wrote to the HHS Office of Inspector General and CMS Thursday for information on potential failures to disclose doctors’ ownership interests in companies that supply medical devices to their own practices. Failure to report financial kickbacks to doctors is a violation of the Physician Payment Sunshine Act. DEMOCRATS WANT $100 MILLION TO HAND OUT FREE DIAPERS: Reps. Barbara Lee of California and Rosa DeLauro of Connecticut on Thursday introduced the End Diaper Need Act to supply low-income families with diapers. The bill is co-sponsored by Reps. Alexandria Ocasio-Cortez and Ilhan Omar. The money would be sent to cities, states, and non-profit groups, which would then help distribute diapers.<doc-sep>Chief Justice John Roberts traded with liberal justices over the fate of a key plank in President Barack Obama's signature health-care legislation while the matter was before the Supreme Court in 2012, according to an adaptation published on Thursday of a forthcoming Roberts biography. The legal battle over the Affordable Care Act was one of the most consequential disputes before the nation's top court since Roberts, a George W. Bush appointee, took the helm in 2005. It has long been reported that Roberts flipped his vote on the central element of the case, eventually siding with the liberals in a 5-4 vote to uphold the Affordable Care Act's individual mandate. But according to Joan Biskupic, the author of "The Chief: The Life and Turbulent Times of Chief Justice John Roberts," that's not the only flip-flop that happened at the time. According to Biskupic, two of the court's liberals, Justices Stephen Breyer and Elena Kagan, flipped on Medicaid expansion, a separate legal issue concerning Obamacare. When the Affordable Care Act was passed, it required states to expand Medicaid coverage to those near the poverty line or risk losing federal funding. According to Biskupic, Breyer and Kagan voted during the court's first conference on the matter, in March 2012, to uphold that requirement. But once Roberts signaled that he was going to switch his vote and uphold the individual mandate, the two justices were "were willing to meet him partway."<doc-sep>
Win McNamee/pool via Associated Press Supreme Court Chief Justice John Roberts, left, Associate Justice Stephen Breyer and Associate Justice Elena Kagan listens as President Donald Trump delivers his first State of the Union address on Jan. 30, 2018. Chief Justice John Roberts was an instrumental force behind a 2012 Supreme Court decision to protect Obamacare but shifted his opinions on several key components of the health care law behind the scenes in the months leading up to the monumental decision, ultimately weakening the law in one critical place, according to an upcoming book about his life. CNN’s Joan Biskupic detailed the backroom negotiations between Roberts and liberal members of the court in her new book, The Chief, which will be released later this month. In an excerpt posted on CNN’s website, Biskupic notes how Robert initially sided with the court’s conservative wing and voted in a private conference to reject a key argument the Obama administration had made in defense of the law’s individual mandate. The provision, a core part of the health care law, required Americans to purchase insurance or pay a penalty. But Roberts was wary of overturning the whole law, as the conservative justices preferred, and over the next few weeks he began to construct an argument to present the individual mandate as a tax, according to Biskupic. The Obama administration had made that argument too, but it hadn’t come up in the initial conversation of the justices, according to the book excerpt. Roberts eventually joined the court’s liberal justices, upholding the mandate on the grounds that it was a constitutionally permissible tax. This provoked outrage from his fellow conservatives and right-leaning lawmakers across the country. Viewed only through a judicial lens, his moves were not consistent, and his legal arguments were not entirely coherent. But he brought people and their different interests together. His moves may have been good for the country at a time of division and a real crisis in health care, even as they engendered, in the years since, anger, confusion and distrust. Criticism on the right ― from insiders and outsiders ― was swift. CBS’ Jan Crawford first reported Roberts’ change in 2012, shortly after the decision was handed down. The latest excerpt adds more detail to his reasoning and details the thinking of two liberal justices. Although the decision on the mandate got the most attention at the time, the ruling also affected the Affordable Care Act’s expansion of Medicaid, under which all states were supposed to open up the program so that it would be available to anybody with income below or just above the poverty line. The conservatives filing the lawsuit had claimed that provision of the Affordable Care Act was coercive to the states. In the initial conference, Biskupic reports, the four liberals rejected that argument and Roberts sided with them. But here, too, Roberts had a change of heart and, according to Biskupic, two liberal justices, Elena Kagan and Stephen Breyer, perceived a deal in the making. They ended up voting with Roberts and the four other conservatives to invalidate part of the Medicaid expansion, effectively making that part of the Affordable Care Act optional for states. Breyer and Kagan had voted in the private March conference to uphold the new Medicaid requirement, and their votes had been unequivocal. But they were pragmatists. If there was a chance that Roberts would cast the critical vote to uphold the central plank of Obamacare ― and negotiations in May were such that they still considered that a shaky proposition ― they were willing to meet him partway. When Ginsburg found out about Roberts’ new position, her first thought was, “It ain’t over till it’s over.” She understood that the process could continue to be fluid, especially in such a monumental case. The Medicaid portion of the ruling turned out to be a lot more important than many people realized at the time, because states with Republicans in charge largely refused to expand their programs. That has changed over time, as even many GOP-controlled states have joined the expansion ― either because governors and state lawmakers decided to embrace it or because voters approved expansion via ballot initiatives. But even today, roughly one-third of the states still have not expanded their programs. That includes three large states in the South ― Florida, Georgia, and Texas.