Federal Officials, Health Associations Applaud Supreme Court’s Decision to Uphold the ACA
On June 17, the United States Supreme Court handed down a third decision centering on the Affordable Care Act (ACA), signed into law by President Barack Obama in March 2010. This time, in California et al. v. Texas et al., the nation’s highest court decided, 7-2, that the plaintiffs in the case, primarily state attorneys general from Republican-controlled state governments, “do not have standing to challenge[the ACA’s] minimum essential coverage provision because they have not shown a past or future injury fairly traceable to defendants’ conduct enforcing the specific statutory provision they attack as unconstitutional”—that is to say, the individual mandate, the law’s requirement that Americans purchase health insurance coverage.
Explaining the core of Justice Breyer’s reasoning in the ruling, SCOTUSblog’s Amy Howe wrote on Thursday that “Six justices joined Breyer’s opinion holding that neither the states nor the individual plaintiffs have standing to challenge the mandate. The individual plaintiffs, Breyer explained, contended that they are harmed, and therefore have a right to sue, because they have to pay each month for health insurance to comply with the mandate. The problem with that argument, Breyer reasoned, is that although the ACA instructs them to obtain health insurance, the Internal Revenue Service can no longer impose a penalty on taxpayers who fail to obtain insurance – and there is no other government action connected to the harm that the individual plaintiffs claim to have suffered, a key requirement for standing. “Nor, Breyer continued, do Texas and the other states have standing to challenge the mandate. Although they alleged that they are injured because their residents, in an effort to comply with the mandate, enroll in state-sponsored programs like Medicaid, which costs the states money, Breyer emphasized that the states have not shown a link between the unenforceable mandate and the decision to enroll.”
Further, Howe wrote, “Breyer also rejected the states’ argument that the mandate imposes other additional costs directly on them – for example, the costs of providing information to beneficiaries and the IRS. Those requirements, Breyer explained, come from other parts of the ACA, rather than the mandate. Because neither the individual plaintiffs nor the states have standing to challenge the mandate, Breyer concluded, the 5th Circuit’s holding that both sets of plaintiffs have standing is reversed, and the court sent the case back to the lower court with instructions to dismiss it.”
In the current political environment, it is highly unlikely that a new major challenge to the law would emerge, given the length of time in which the law has been in place (more than twelve years), and the fact that Democrats control the White House, the U.S. Senate, and the U.S. House of Representatives, and that this was the third attempt by Republicans to undo the law in the courts. More than 10.7 million Americans currently obtain their health insurance through the ACA’s health insurance exchanges, while core provisions of the law remain extremely popular, including the ban on discrimination against individuals with pre-existing conditions, the ban on lifetime limits for coverage, and the fact that young people can remain on their parents’ health plans until age 26. Republicans in Congress had vowed to come up with a substitute to replace the ACA, but in the past 12 years have failed to do so, making their campaign to undo the law an uphill battle with the public. Meanwhile, Medicaid expansion under the law has provided health insurance to tens of millions of Americans; and the internal health system reforms around quality, the creation of accountable care organizations (ACOs), and other elements that touch on healthcare delivery and health system operations, never were controversial.
That said, the Washington Post’s Amy Goldstein, Matt Viser and Mike DeBonis wrote on Wednesday that “Some Republicans conceded Thursday that, after a decade of repeal votes, political campaigns and legal challenges, their quest to nullify the entire law probably is dead. Confronted with a 7-2 ruling that marked the third time the high court has preserved the law, some GOP members of Congress suggested that they would, instead, start plotting legislatively to trim back parts of it.” And they quoted Republican Senators Josh Hawley and Roy Blunt of Missouri, with Hawley stating that “The ACA is still in place. So I think what we’ve got to do now is think about what we can do in terms of reforms . . . that will protect people with preexisting conditions, but then also create new choices and options. Hopefully this will be a spur for some new ideas and new proposals, because pretty much all that’s been on ice since I’ve been here, because everybody said, ‘Well, let’s see what happens with the court decision.” Meanwhile, Blunt told the press on Wednesday that “The Affordable Care Act gets constantly woven deeper and deeper into the system. It’s eventually going to be pretty hard to unravel from the system. The court had a chance to do that today and didn’t do it.”
A 7-2 margin in deciding the case
As Adam Liptak wrote in The New York Times on Thursday, “The margin of victory was wider than in the earlier cases, with six members of the court joining Justice Stephen G. Breyer’s modest and technical majority opinion, one that said only that the 18 Republican-led states and two individuals who brought the case had not suffered the sort of direct injury that gave them standing to sue. Chief Justice John G. Roberts Jr., who had cast the decisive vote to save the law in 2012, was in the majority. So was Justice Clarence Thomas, who had dissented in the earlier decisions. ‘Whatever the act’s dubious history in this court,’ Justice Thomas wrote in a concurring opinion, ‘we must assess the current suit on its own terms. And, here, there is a fundamental problem with the arguments advanced by the plaintiffs in attacking the act — they have not identified any unlawful action that has injured them.’ Justices Sonia Sotomayor, Elena Kagan, Brett M. Kavanaugh and Amy Coney Barrett also joined Justice Breyer’s majority opinion. At Justice Barrett’s confirmation hearings last year, Democrats portrayed her as a grave threat to the health care law.”
As Liptak wrote, “The court did not touch the larger issues in the case: whether the bulk of the law could stand without a provision that initially required most Americans to obtain insurance or pay a penalty. ‘This ruling reaffirms what we have long known to be true: the Affordable Care Act is here to stay,’ Mr. Obama said on Twitter.” In other words, the decision hinged on the determination by the seven justices—Breyer, Roberts, Sotomayor, Kagan, Kavanaugh, Coney Barrett, and, in a separate concurring decision, Thomas, that the plaintiffs had failed to achieve standing by showing conclusively that they had been injured by the law. Justices Samuel Alito and Neil Gorsuch dissented.
President Joe Biden released a statement published on the WhiteHouse.gov website. It began, “The Affordable Care Act remains the law of the land. Today’s U.S. Supreme Court decision is a major victory for all Americans benefitting from this groundbreaking and life-changing law. It is a victory for more than 130 million Americans with pre-existing conditions and millions more who were in immediate danger of losing their health care in the midst of a once-in-a-century pandemic.”
Further, President Biden said in the statement, “It is a victory for every American who, prior to the Affordable Care Act, stayed up at night staring at the ceiling, wondering whether they would lose everything if they or a loved one got sick. Because of this law, they don’t have to worry about being denied coverage due to a pre-existing condition like diabetes or watching their coverage being capped during a cancer treatment. Because of the law, they are able to get free preventive screenings that can save their lives and improve their health. Today’s victory is also for all the young people who can stay on their parents’ insurance plan until they turn 26 years old, and for the millions of low-income families and people with disabilities receiving health care because their states expanded Medicaid under this law. After more than a decade of attacks on the Affordable Care Act through the Congress and the courts, today’s decision – the third major challenge to the law that the U.S. Supreme Court has rejected – it is time move forward and keep building on this landmark law.”
And Health and Human Services Secretary Xavier Becerra, who has been deeply involved in defending the ACA across its history, released a statement Thursday afternoon that was posted to the Department of Health and Human Services (HHS) website. Secretary Becerra said that “Once again, the Supreme Court has made clear that the landmark Affordable Care Act is the law of the land. Today’s ruling is a victory for all Americans, especially people with a pre-existing condition or anyone who was worried they could be forced to choose between their health and making ends meet. Health care should be a right -- not a privilege -- just for the healthy and wealthy. Today’s decision,” Secretary Becerra said, “means that all Americans continue to have a right to access affordable care, free of discrimination. More than 133 million people with pre-existing conditions, like cancer, asthma or diabetes, can have peace of mind knowing that the health protections they rely on are safe. Women who need access to birth control, life-saving maternity care and preventive care can rest easy, knowing that their care is protected and covered. Seniors and people with disabilities can breathe easy knowing their health protections will continue. Individuals who have faced discrimination can continue accessing care without fear. And people relying on Medicaid and Medicare should know these programs are stronger than ever.”
Further, Becerra said, “As a Member of Congress, I helped draft and pass the ACA. As the Attorney General of California, I took this case all the way to the Supreme Court. And now, as Secretary, I will continue to stand up and stand with you to protect access to affordable health care. The COVID-19 public health emergency has underscored the importance of safeguarding this life-saving law and it is only fitting that the Supreme Court recognized its lawfulness. Now we can build on the Affordable Care Act by implementing the investments that President Biden has made in America’s health with the American Rescue Plan and through the expanded Special Enrollment Period. Every American should have access to the tools they need to lead healthy, full lives.”
And Chiquitia Brooks-LaSure, the Administrator of the Centers for Medicare & Medicaid Services (CMS), said in a statement posted to the agency’s website that “Millions of Americans can breathe a sigh of relief following today’s Supreme Court 7-2 ruling upholding the Affordable Care Act. This victory assures access to affordable and comprehensive health insurance for patients and families across the country.”
Indeed, as Brooks-LaSure stated, “From my early career on the House Ways and Means Committee, I worked on this life-saving law. And later in a leadership post at CMS, I worked to implement the ACA – and the results are clear. Tens of millions of Americans can no longer be discriminated against due to pre-existing conditions like cancer, asthma, or diabetes. Thanks to the ACA, millions of people have access to preventative health care at no cost and Medicare prescription drug coverage was made more affordable by closing the gaps in coverage. Through the ACA, and hand-in-hand with CMS, dozens of states have expanded Medicaid – bringing quality coverage to our family and neighbors who need it most. We will continue to partner with states because we know 4 million more Americans stand to gain access to quality health coverage in the remaining states. So,” she said, “our work is far from finished. CMS is focused on building on the successes of ACA to further expand access to health coverage. Thanks to the ACA and President Biden's American Rescue Plan, coverage on HealthCare.gov is more affordable than ever before. We are continuing to see Americans sign up for coverage through the Special Enrollment Period, which runs through August 15th, and we know Americans are taking advantage of the opportunity with over 1.2 million already signed up.”
And, she added, “When it comes to making sure every American--in every community--has access to comprehensive, affordable health care, we'll continue to work to ensure that no one is left out, left behind, or left on the sidelines. That's our goal and our promise.”
National associations applaud the decision
National healthcare associations applauded the decision. “We believe the Supreme Court rightly concluded this case does not belong in court, as the challengers have not suffered any injury. The ACA remains the law of the land and a foundational component of health care and coverage for more than 300 million Americans. After a year filled with unprecedented loss when reliable comprehensive health coverage has never been more important, this decision protects the stability of health coverage for people with pre-existing conditions, hardworking families, seniors, and other Americans who need it most," said AHIP CEO Matt Eyles, adding that "With more than one million more people having already signed up for coverage during this special enrollment period and millions more receiving their care through the ACA’s Medicaid expansion, it is clear that Americans agree we should continue to build on the ACA to improve coverage and care for everyone."
"The more than 30 million Americans who secured health insurance under the Affordable Care Act can again breathe a sigh of relief. But our work is far from over," said AHA President Rick Pollack. "We need to redouble our efforts to close coverage gaps and make care affordable and accessible for everyone, all while continuing to fight COVID-19 and encouraging more Americans to get vaccinated. The AHA is eager to partner with Congress and the Biden administration to make sure all Americans can achieve their highest potential for health."
“Today’s decision by the U.S. Supreme Court is a victory for patients and for the gains in health care coverage achieved through the Affordable Care Act. The American Medical Association is pleased that the high court rejected the challenge to the ACA, thereby upholding critical patient protections that are improving the lives and health of millions of Americans, particularly amid a global pandemic," said Gerald Harmon, M.D., president of the American Medical Association (AMA).
President Biden, Secretary Becerra, Administrator Brooks-LaSure, and other members of the Biden administration, are discussing possible next steps to shore up and enhance the ACA, including potentially proposing a public option for health insurance. Over time, the core ACA has gained popularity, despite much confusion and misinformation over the years in the minds of the public around its precise provisions. A Kaiser Family Foundation poll last month found that, overall, 53 percent of Americans approved of the law, while 35 percent disapproved of it. There remains, however, intense division by party affiliation; as of February 82 percent of Democratic-identified voters approved of the ACA, while only 10 percent disapproved, while 77 percent disapproved of it, and only 15 percent approved. Among independents, it was 54-32.
