On June 17, 2021, the Patient Protection and Affordable Care Act, aka ACA, survived yet another challenge at the Supreme Court. As originally enacted, the ACA had several key provisions, three of which merit mentioning here. The first is the individual mandate, which requires most Americans to maintain “minimum essential” health insurance coverage or else pay a penalty.[1] The second provision of the Act is the Medicaid expansion. The ACA expands the scope of the Medicaid program and increases the number of individuals the states must cover. The third provision provides access to insurance for individuals with pre-existing conditions. The metaphor of a three-legged stool has often been used to describe the ACA. Leg# 1, providing access to insurance for uninsured Americans with pre-existing conditions (aka “guaranteed issue and community rating”). Leg# 2, to insure a nationwide pool, a mandate that every individual in the country buy health insurance or else pay a financial penalty with their tax return, and leg#3, creating a system of tax credits, or subsidies, to enable middle- or lower-income people to afford health insurance offered in “Exchanges” set up by the federal government or states.
Naturally, these key provisions have spawned the principal lawsuits. In National Federation of Independent Business v. Sebelius,[2] the Court was presented with the question whether the individual mandate is a constitutional exercise of Congress’s power to levy taxes. The majority held that although the mandate is not authorized under the Commerce Clause or the Necessary and Proper Power Clause, it is nonetheless a valid exercise of Congress’s power under the Taxing Clause. Next was the contraception mandate challenge in Burwell v. Hobby Lobby.[3] There, the issue was whether the Religious Freedom Restoration Act of 1993 (RFRA) permits the United States Department of Health and Human Services (HHS) to demand that three closely held corporations provide health insurance coverage for methods of contraception that violate the sincerely held religious beliefs of the companies’ owners. The majority held that the regulations that imposed this obligation violated RFRA. Hobby Lobby was followed by King v. Burwell,[4] where the Court decided the question whether individuals in states that opted not to build their own exchanges are eligible for health insurance subsidies. There the Court determined that the plain language of the Act extended tax credits to federally created exchanges as well as those created by the states. Finally, in June 2021, the Court decided (more like punted) another ACA case. In California v. Texas,[5] the Court was presented with the issue of whether the ACA’s §5000A(a)’s minimum essential coverage provision is unconstitutional as a result of 2017 Amendments effectively nullifying the penalty for not having insurance to $0. In a majority opinion, Justice Breyer found that the challengers did not have standing to challenge §5000A(a)’s minimum essential coverage provision because they did not show a past or future injury fairly traceable to the defendants’ conduct, enforcing the specific statutory provision they attacked as unconstitutional.
So, does the ACA have the mythological nine lives because it keeps surviving these challenges at the Supreme Court? And if so, what are the impacts on minorities? To quote Bob Dylan, “the answer, my friend, is blowin' in the wind.”
The ACA’s impact on minority populations cannot be gainsaid. For example, “studies show that Medicaid expansion states experienced significant coverage gains and reductions in uninsured rates among the low-income population broadly and within specific vulnerable populations.”[6] More significant is that as of the time of this writing, “twelve states have refused to expand Medicaid, leaving millions of poor Americans without health coverage.”[7] It goes without saying that most of these poor Americans are minorities. The states that have not adopted Medicaid expansion are Alabama, Florida, Georgia, Louisiana, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.[8] Some of these states (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas) have large minority populations. All of the non-expansion states are controlled by Republicans, except Kansas, North Carolina, and Louisiana, which have Democratic governors, but have Republican state legislative majorities. I leave it to you dear reader, to draw your own conclusions.
As a result of the COVID-19 pandemic, millions of people lost their jobs as well as their employer-based health insurance benefits. For many of those who lost their jobs, Medicaid was the only way of gaining health coverage. However, for non-expansion states, Medicaid eligibility for adults remains limited. This is because some uninsured poor adults have incomes above their state’s eligibility for Medicaid but below poverty, the minimum income eligibility for tax credits through the ACA marketplace.[9] Although the March 2021 COVID-19 relief legislation, aka the American Rescue Plan Act of 2021, addresses some of these coverage gaps, it is a temporary fix lasting for two years, retroactive to January 1, 2021. The bottom line is that the ACA has provided subsidized health insurance for millions of uninsured Americans, improved health outcomes for many minorities, increased coverage for young adults, emphasized prevention as opposed to treatment, and ensured that those with preexisting conditions can no longer be denied care, to mention but a few.
Were the ACA to be held invalid, millions would suffer, and minorities would be particularly harmed. So, like the mythological cat, the ACA has cheated death four times. Five more to go?
[1] 26 U.S.C. § 5000A (2014). Congress Amended the Act in 2017 by setting the penalty to $0, effective 2019.
[2] Nat'l Fed'n of Indep. Bus. v. Sebelius, 567 U.S. 519 (2012).
[3] Burwell v. Hobby Lobby, 573 U.S. 682 (2014).
[4] King v. Burwell, 576 U.S. 473 (2015).
[5] California v. Texas, 141 S. Ct. 2104 (2021).
[6] See Madeline Guth et al., The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020, Kaiser Fam. Found. (March 17, 2020), https://www.kff.org/medicaid/report/the-effects-of-medicaid-expansion-u….
[7] Sarah Kliff, Obamacare’s Survival Is Now Assured, but It Still Has One Big Problem, N.Y. Times (June 28, 2021), https://www.nytimes.com/2021/06/28/upshot/medicaid-expansion-democrats-….
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