A federal appeals court in Cincinnati ruled the federal health reform law constitutional, the latest in a string of conflicting rulings regarding the Patient Protection and Affordable Care Act.

However, a conservative judge on the three-judge panel, Jeffrey Sutton, wrote in the ruling that he believes the individual mandate is legal. The subject of most of the more than 20 federal court challenges to the law mandates that, starting in January 2014, all Americans either buy health insurance or face a fine. That provision is central to the Patient Protection and Affordable Care Act, the landmark legislation passed in March 2010.

Sutton, an appointee of George W. Bush, and Judge Boyce Martin Jr., a more liberal judge on the Sixth Circuit Court of Appeals, supported the Obama Administration in the appeal of a Michigan case involving the Thomas More Law Center, whose lawyers argued that the Commerce Clause of the U.S. Constitution does not grant Congress the power to regulate economic “inactivity.”

“Far from regulating inactivity,” Martin wrote, “the minimum coverage provision regulates individuals who are, in the aggregate, active in the health care market…because of two unique characteristics of this market: (1) virtually everyone requires health care services at some unpredictable point; and (2) individuals receive health care services regardless of ability to pay.”

The myriad challenges are expected to eventually wind toward the U.S. Supreme Court.

The case has been ruled constitutional in six cases, overturned twice, dismissed for lack of standing in eight cases, according to Kaiser Health News. Nine other cases are pending, as are five other appeals, where oral arguments are scheduled over the next three months.

In the ruling in Cincinnati, Judge James Graham, the third panelist and an appointee of President Ronald Reagan, offered a more conservative take on the Commerce Clause.

“If the exercise of power is allowed and the mandate upheld,” Graham wrote in his dissent, “it is difficult to see what the limits on Congress Commerce Clause authority would be. What aspect of human activity would escape federal power? The ultimate issue in this case is this: Does the notion of federalism still have vitality? To approve the exercise of power would arm Congress with the authority to force individuals to do whatever it sees fit … as long as the regulation concerns an activity or decision that, when aggregated, can be said to have some loose, but-for type of economic connection, which nearly all human activity does.”