The Supreme Court Monday punted on the constitutional merits of a religious freedom challenge to the Affordable Care Act. The court said it was feasible to satisfy religious groups and women seeking contraception and sent the case back to the lower courts.

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AUDIE CORNISH, HOST:

Today the U.S. Supreme Court avoided making a decision on birth control coverage for employees. This is the coverage guaranteed under the Affordable Care Act. Instead of resolving a clash between religious objectors and the law, the Court said there’s the possibility of a compromise, so it unanimously booted the case back down to the lower courts. The justices gave instructions to take sufficient time for the two sides to work it out.

To talk through what happened, NPR legal affairs correspondent Nina Totenberg is in the studio. And Nina, if you had to write a headline for this story, what would it be?

NINA TOTENBERG, BYLINE: The justices punted. You know, Audie, I don’t want to be flip about this, but they said to the parties, you folks negotiate for now, and the appeals courts below can deal with this problem for now; and then you can come back here later – much later.

CORNISH: So give us a little more detail. What was this case all about?

TOTENBERG: Well, the Affordable Care Act, among other things, seeks to deal with one of the major health care costs for women – birth control. It requires all employers who provide health insurance to include free contraception coverage for their employees. Religiously affiliated nonprofits like universities, hospitals and charitable organizations can opt out by notifying either the government or their insurer of their objections. The government then works with the insurer to provide the coverage independently.

The opt-out provision was added to the health care law as an attempt to accommodate the objections of some religious nonprofits, but it didn’t go far enough for them. They contended that notifying the government or the insurer of their objections would make them enablers of birth control via a different route. They want to be completely exempt, to be treated the same way that houses of worship are treated, meaning that their employees and, in the case of universities, their students would have no birth control coverage.

CORNISH: So those religious nonprofits that rejected this go to the court, and they lost in most places, right?

TOTENBERG: They lost in 8 out of 9 appeals courts. But one ruled in their favor, so there was a conflict. And the Supreme Court agreed to resolve the issue. After the death of Justice Antonin Scalia, however, that turned out to be very difficult, and the court looked as though it might be headed for a 4 to 4 tie.

Less than a week after the oral argument in the case, the justices floated a compromise idea – no written notification and a package of free birth control coverage from the same insurer. The court asked the two sides to file briefs responding to its suggestions.

What it got back was less than totally enthusiastic, especially from the government which warned of important practical problems. Nevertheless, today, in an unsigned unanimous opinion, the court chose to treat those responses in the rosiest of fashions. The court then sent all the birth-control cases – and I think there are now 17 of them – back to the lower courts with the instruction to look for a way to better reconcile religious objections with the need to provide free birth control coverage for women who work at religiously affiliated universities, hospitals, charities…

CORNISH: Wow.

TOTENBERG: …Et cetera.

CORNISH: Sounds like a tall order.

TOTENBERG: Uh-huh.

CORNISH: So is there another agenda here?

TOTENBERG: Well, probably there are many agendas. First is the court’s desire to avoid a 4 to 4 tie which lets stand the judgment of the lower court, meaning that in this case, for instance, there would not have been one legal rule for the whole country.

Another is Justice Anthony Kennedy, who would’ve been a fifth vote if he sided with the court’s liberals in this case or, if he went the other way, a fourth vote for a tie. And he seemed very torn at oral argument. And third, this is an eight-justice court with a big, fat vacancy. And today’s action ensures that nothing will be decided by the time of the election.

CORNISH: Wait, so what does that mean – that really nothing will be decided before the election?

TOTENBERG: Well, in the starkest terms, if Donald Trump wins, he says he’ll fill the ninth seat with a conservative, and the court likely would strike down the birth control mandate as a violation of religious rights. If, on the other hand, the Democratic nominee wins, then the pendulum swings to women’s reproductive rights and the government’s right to legislate to protect women’s health.

CORNISH: So what did the court actually decide today?

TOTENBERG: It was extremely explicit about that. It said it was deciding nothing. And in the meantime, the coverage continues as it is today.

CORNISH: That’s NPR’s Nina Totenberg. Nina, thanks so much.

TOTENBERG: Thank you, Audie.

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NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

NPR’s Robert Siegel talks to physician and author Siddhartha Mukherjee about how the fight against cancer has changed so dramatically in this era of precisely targeted treatments.

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ROBERT SIEGEL, HOST:

When two people catch the flu in the same flu season, odds are they’ve been infected by the same virus with nearly the same genetic mutations. And that’s one reason it makes sense for millions of us to get the same flu shot. But when two women, say, have breast cancer, the genetic mutations present in one patient can be vastly different from those in the other. And that goes for other kinds of cancer, too.

The oncologist, Siddhartha Mukherjee, writes in this Sunday’s New York Times Magazine about a trend in fighting cancer that’s based on that fact, precisely targeted treatment that breaks some old rules. Siddhartha Mukherjee who wrote the Pulitzer Prize-winning book the “Emperor of All Maladies: A Biography of Cancer,” joins us now. Welcome to the program.

SIDDHARTHA MUKHERJEE: Thank you, Robert.

SIEGEL: How do these advances change the way that you deal with your patients?

MUKHERJEE: They’ve changed my interactions with patients dramatically. Ten years ago, there was something formulaic about treating cancer patients. You know, you’d have a patient with lymphoma and we treat them with, you know, a classical culmination chemotherapy.

These days, I take a very different look. I think to myself, well, OK, here’s a patient with cancer, how much information can I glean from this individual patient’s tumor? Can I understand something about its biology? Can I understand something about its particular behavior, its gene mutations? And now can I cleverly tailor some therapy? It’s far, far from where we want to be because I have only a few tools, but I try to use them in the most effective manner possible.

SIEGEL: You acknowledge that when therapies are in fact tailored to the individual patient and to, say, medications are used in novel ways or off-label ways, we’re talking about not only extremely expensive medicine but medicine that might not be reimbursed by insurers because it is novel and it’s not standard.

MUKHERJEE: Absolutely, this has become a new battle. You know, it’s we – on one hand, doctors are battling cancer, but on the other hand, they’re also battling a relatively old system of reimbursement and understanding disease, which is not personalized. And there are costs associated.

I’ll give you a very concrete example. There’s a patient of mine who I was convinced would respond to immunological therapy, new immunological therapy, except – this was several months ago – it was not still indicated for that particular cancer. And ultimately, this resulted in a very complicated battle across the insurance companies, the individual patient’s, et. cetera. These battles are common.

SIEGEL: Because I’ve read your work, because I’m familiar with the public TV series that’s been based on it, I trust your instincts about creative experimentation using the medications off-label, say, or doing procedures in novel ways. But isn’t there a risk in that kind of medicine of a lot of quackery and much snake oil being sold in the name of idiosyncrasy by people whom I shouldn’t trust as much as I trust you?

MUKHERJEE: Absolutely, and, you know, I clearly point that out in the piece that, you know, medicine needs standards and guidelines. We need standardized medicines. I mean, we’ve seen this. You know, you go to a website and someone is offering some snake oil for something or the other in cancer. It’s a very important thing to remain within guidelines, but it also needs some freedoms, some creative freedoms. And if you don’t fall appropriately in those creative freedoms, I think we’ll be badly stuck.

SIEGEL: Do newly-minted oncologists who are finishing their residencies in this era, do they know a lot more than oncologists in the same situations 15 years new?

MUKHERJEE: Absolutely, they know – I mean, I was in rounds this morning with a fellow, and I was just remarking how much the stable landscape has changed. One of the most incredible things is that these newly-minted oncologists know so much more about cancer.

They talk about genes, they talk about genetic mutations, targeted therapies, immune therapies, words that, you know, barely were in the vocabulary, at least in the hospital. It was certainly in the vocabulary of science forever, but they were not in the vocabulary in the hospital. And all of a sudden they are part of the vocabulary of the hospital. And the way they evaluate patients, the way they evaluate a kind of journey has changed. It’s quite remarkable.

SIEGEL: Even though you and other oncologists now understand tumors and cancer cells much better than people did even 10 or 15 years ago, it hasn’t yet hugely altered the chances of survival. Do you feel fairly hopeful about that? That is, does it seem to you that the trajectory is going towards still greater understanding of the disease and ultimately some kind of cure?

MUKHERJEE: I feel absolutely hopeful. And part of the reason I wrote this piece was that it began to restore my hope as I, as an oncologist, began to see these dreams about, you know, unique fingerprints of cancer, immune therapies, targeted therapies. As I began to see these dreams move from the scientific literature publications into the clinical literature, it almost restored my faith in my own discipline.

I describe this in my book, “The Emperor of All Maladies” – I describe a moment about 10 years ago, when I felt very despondent about what was happening in cancer care. It seemed to be stuck. I just – quite the opposite now, it feel it kind of – it feels like the blood is flowing. And sometimes the blood flows in wrong directions, but it’s still flowing, and there’s a kind of new energy that one feels in cancer wards.

SIEGEL: That was oncologist Siddhartha Mukherjee, talking about this Sunday’s New York Times Magazine article on improvising ways to treat cancer. He also has a new book out this month called, “The Gene: An Intimate History.” Siddhartha Mukherjee, thanks for talking with us.

MUKHERJEE: Thank you very much.

Copyright © 2016 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.