ACA’s future hinges on delayed Supreme Court decision

Over the past decade, there have been many legal challenges to the Patient Protection and Affordable Care Act, all of which have been struck down. However, a new court case that is expected to be heard in 2021 now seems as though it could actually pose a threat to the ongoing existence of the law as it currently exists.

The suit was spurred by a 2018 ruling by a Texas court that the ACA was unconstitutional because lawmakers the previous year stripped out the individual mandate, which was the basis of the law being considered constitutional in a 2012 Supreme Court decision. Technically, the case awaiting consideration from the Supreme Court is a challenge to that ruling, but it has been pushed to the next term, which runs from October 2020 to June 2021, according to Reuters. That leaves room for it to be decided before the election on Nov. 3, but it's unlikely the Court would issue a ruling before the nation votes.

Given the current makeup of the Court, some observers believe it possible that the ACA could be struck down, in whole or in part. That would potentially throw the nation's health care system writ large into chaos, given that it has shifted dramatically in the past decade to conform to the current legal framework.

The Supreme Court's next ACA ruling is likely to be a significant one.

A deeper understanding
Specifically, the issue here is that the 2012 ruling found the ACA's individual mandate was constitutional because it amounted to a tax imposed on people who went without health insurance, Reuters noted. However, because the penalty for the mandate was reduced to zero in the 2017 tax reform bill, the argument – which the Texas court agreed with, and which was upheld by the 5th U.S. Circuit Court of Appeals last last year – was that it was no longer a tax and, thus, no longer constitutional by the parameters laid out by the Supreme Court several years prior.

Currently, it is not clear which aspects of the law could potentially be struck down in such a decision. For instance, there doesn't seem to be much support – even within the Trump administration, which has not been in favor of the ACA – to strip out the law's protections for people with pre-existing conditions, among other measures.

Where the public stands
When it comes to the decision to delay in particular, Americans seem more or less divided on how they believe the Supreme Court should have proceeded, according to a recent poll from The Hill and HarrisX. While 51% of respondents felt a decision should have been handed down prior to the presidential election in November, that also means 49% felt the Court was right to delay. That leaves the poll within the margin of error (3.1%) and shows just how split the public is on the decision.

On the other hand, a decision to fundamentally alter or entirely strike down the ACA may not prove popular with the general public; a recent Kaiser Family Foundation poll found that half of Americans have a generally favorable view of the law, while fewer than 2 in 5 had an unfavorable view. Similar levels of support were seen across just about every age group, and these trends have grown since 2017. April of that year was the last time there was a split in favorability (46% on each side), and the gap has widened toward acceptance on a slow but steady basis ever since.

What's at stake?
Of course, health care has become an increasingly important topic in recent months, as the novel coronavirus pandemic continues to take its toll on the world. However, KFF data suggests that the ACA has likely played a significant role in adding layers of protection for millions of Americans, helping to insulate from both health and financial risk amid the outbreak.

The most recent complete data shows that from 2010 – when the ACA was first enacted – to 2018, about 19 million more people have obtained health coverage, shrinking the uninsurance rate from 17.8% of non-elderly adults to 10.4%. Improvements were seen for people gaining coverage through employer-sponsored plans (up 1.8 points to 57.5%), non-group or individual plans (up 1.2 points to 7.2%) and Medicaid or other public coverage options (up 4.3 points to 24.8%). The latter may be significantly important in this examination specifically because the ACA encourages states to broaden their Medicaid programs.

Furthermore, while nearly 28 million people nationwide still didn't have coverage through the end of 2018 – and some estimates show that number probably hasn't changed much in the last year-plus – it nonetheless represents a significant shift in coverage trends at a time when it is now sorely needed.

Certainly, insurers, care providers and policyholders alike will have to keep a careful eye on how this case proceeds over the next year or so, as it could end up dramatically reshaping the landscape for all involved.