Almost since the day it was first passed, the Patient Protection and Affordable Care Act has been the subject of numerous legal challenges. To date, there have been few effective challenges to any aspects of the ACA, and the latest rebuke of these attempts came from the highest court in the land.
In mid-June, the U.S. Supreme Court rejected another effort to challenge the ACA — this time in California v. Texas, which contested the constitutionality of the law's provision that all Americans must carry health insurance. The National Law Review said that this is the third major judicial challenge that was rejected by the Supreme Court, and this time, the decision was a 7-2 majority dismissing the case for lack of standing.
Initially, the challenges to the law — beginning in 2012 — sought to argue that the individual mandate (and a penalty for not carrying coverage) represented a Congressional overreach of its taxation powers. Then, in 2017, the financial penalties for going without health insurance were reduced to zero because of repeated failed attempts to "repeal and replace" the ACA. That, in turn, prompted nearly 15 states, including Texas, to once again challenge the law's constitutionality on the grounds that if the individual mandate could not be applied, and it was considered "inseverable" from the broader law, then the entire legislation needed to be struck down. That challenge failed as well.
The most recent challenge was determined to be without standing because the states in question could not prove how they were in any way harmed by the individual mandate, which they alleged was illegal. As such, the Supreme Court ruled they could not proceed with the suit even as lower courts upheld their argument of the ACA's unconstitutional nature.
What was the reaction?
There have been understandable concerns about what would happen to millions of Americans if the ACA were to be repealed in whole or in part, but now with this latest challenge struck down for lack of standing, these types of cases may be reaching the end of the line. As reported by Health Care Dive, a number of organizations representing major players in the health care industry — including the American Medical Association, America's Essential Hospitals, and the American Hospital Association — reacted swiftly to the ruling, saying this was a positive for providers and patients alike.
Why? It's estimated that various aspects of the ACA have led to some 30 million Americans — more than 9% of the total U.S. population — gaining health insurance, in many cases for the first time. Not only did the law help create state and federal marketplaces where millions could buy coverage (usually with discounted premiums), but it also expanded Medicaid in many states to provide a safety net for people who previously made too much to qualify for the program but not enough to be able to afford coverage on their own. As such, there are many parts of the country where so-called "churn" of people moving back and forth between qualifying or not-qualifying for Medicaid is no longer an issue, and even if it was, they now have subsidized coverage from the exchanges to fall back on.
However, in the oral arguments before the Supreme Court, the word "standing" came up early and often (nearly 60 times, in all) and even the justices who might have been opposed to the law on ideological grounds mostly expressed that they could not see where the case was coming from, with Justice Neil Gorsuch openly questioning who the plaintiffs sought to enjoin, and from what.
In the past, decisions regarding the constitutionality of the ACA have clearly left additional room for interpretation and potential future suits. However, this decision — and specifically, who joined the majority — likely means that any additional suits in this vein would further fail to gain headway with the Supreme Court, signaling the end of the line for legal challenges to the ACA.
What comes next?
Even as the most recent decision all but closes the book on potential challenges to the ACA as a whole, it's believed that new arenas may now open. MSNBC notes that while there is a segment of the country that still opposes the law, it's relatively small in comparison with where opposition was even five years ago, and seems to still be shrinking over time.
Instead, it's increasingly likely that the battlefield over the national approach to health care, costs and coverage is going to shift within the next few years. That new focus could include states where Medicaid expansion has been intentionally stymied, the expansion of Medicare to lower qualification ages, the introduction of public options and more. Challenges will potentially continue to crop up out of those efforts, but the ACA itself — with its mandatory minimum coverages, the ongoing operation of state and federal insurance exchanges, and perhaps even federal subsidies to help people afford coverage — is likely to be effectively bulletproof at this juncture.
What's left to address?
Indeed, even as millions have been able to obtain coverage in the past decade thanks to the ACA's various provisions, The Associated Press recently highlighted that there are still tens of millions more who didn't have coverage before the pandemic hit, and many lost their coverage during that period of more than a year as well. The recent COVID relief bill (with its $1.9 trillion price tag) helped deal with some of these issues, but many of its fixes were always intended to be temporary. As such, more permanent solutions may need to come down the pike within the next few years.
The health insurance industry, care providers and even average Americans would be wise to keep a close eye on all these developments in the months and years ahead so they know how all decisions at the federal level will end up affecting them.