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Supreme Court upholds health care subsidies in states without exchanges
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On June 25, the U.S. Supreme Court ruled 6 to 3 in King v. Burwell, stipulating that the Internal Revenue Service may extend tax credits and premium subsidies for health insurance to consumers who purchase insurance through state or federal exchanges under the Affordable Care Act.
The ACA was passed by Congress and signed into law in 2010.
The court began hearing oral arguments for King v. Burwell in early March.
The plaintiff, David King, a Vietnam veteran from Virginia, was eligible to purchase health insurance with a monthly premium of $648 for $275; the remaining $373 was to be covered by a subsidy. However, King expressed a desire not to have the subsidy or buy any health insurance, according to Amy Howe of SCOTUSblog.
The defendant is Sylvia Mathews Burwell, Secretary of Health and Human Services.
King and three other Virginia residents filed a lawsuit challenging the government’s interpretation of the ACA to allow subsidies for anyone who purchases health insurance through an exchange. The lower federal courts rejected their argument, and in November 2014, the Supreme Court agreed to hear the case.
Chief Justice John Roberts delivered the majority opinion, which was shared by Justices Anthony Kennedy, Ruth Bader Ginsberg, Sonia Sotomayor, Stephen Breyer and Elena Kagan.
Justice Antonin Scalia delivered the dissenting opinion and was joined by Justices Samuel Alito Jr. and Clarence Thomas.
“The combination of no tax credits and an ineffective coverage requirement could well push a State’s individual insurance market into a death spiral,” Roberts wrote. “It is implausible that Congress meant the Act to operate in this manner. Congress made the guaranteed issue and community rating requirements applicable in every State in the Nation, but those requirements only work when combined with the coverage requirement and tax credits. It thus stands to reason that Congress meant for those provisions to apply in every State as well.”
Roberts continued: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.”
In the dissenting opinion, Scalia characterized the ruling as “not merely unnatural; it is unheard of.”
“Who would ever have dreamt that ‘Exchange established by the State’ means ‘Exchange established by the State or the Federal Government?’” Scalia wrote. “Little short of an express statutory definition could justify adopting this singular reading.”
Scalia continued: “Worst of all for the repute of today’s decision, the Court’s reasoning is largely self-defeating. The Court predicts that making tax credits unavailable in States that do not set up their own Exchanges would cause disastrous economic consequences there. If that is so, however, wouldn’t one expect States to react by setting up their own Exchanges? And wouldn’t that outcome satisfy two of the Act’s goals rather than just one: enabling the Act’s reforms to work and promoting state involvement in the Act’s implementation?”
After the ruling, Howe noted that a decision in favor of the plaintiff would have had far-reaching political and economic consequences.
“A ruling for the challengers today could have had effects far beyond the insurance markets and the wallets of people who would no longer receive subsidies: it almost certainly would have carried over into both the political arena — as the people who could no longer afford health insurance directed their frustration at elected officials — and the stock market,” Howe wrote.
In 2012, the Supreme Court upheld a provision of the ACA requiring everyone to purchase health insurance or pay a fee or penalty. – by Matt Hasson
Perspective
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Scott A. Edmonds, OD, FAAO
The U.S. Supreme Court’s decision to uphold health care subsidies and extend tax credits in states without exchanges sends another clear message that the court will continue to support the spirit of the Affordable Care Act and will use its power to clarify and strengthen the law. In the 6-3 ruling, the majority opinion was delivered by George W. Bush appointee Justice John Roberts. He was joined in the decision by Justice Kennedy, another justice appointed by a republican president, as well as by Justices Ginsburg, Sotomayor, Breyer and Kagan, all democratic presidential appointees.
The court’s break from the traditional leanings of the majority conservative make-up to consistently support the logical implementation of the Affordable Care Act (ACA) is refreshing to the advocates of health care reform. The court also ruled to uphold the provision of the ACA requiring everyone to purchase health insurance or pay a fine in 2012.
The ACA was passed “… to improve health insurance markets …,” Justice Robert noted. The law was not well vetted in Congress, as it was passed with a fast and controversial vote. There have been many practical challenges and inconsistencies in the implementation of this law, and there continue to be examples where the opposite effect of the intent has become reality. Rather than make rulings that would weaken the law however, the court continues to rule to support the initial premise.
For those of us who are providers of health care, the underlying premise of the ACA is to provide a broader base of patients that have health insurance to cover preventive primary care health services. Using these encounters to identify potential pathology by evaluating family history, lifestyle and early physical findings is a more logical and cost effective health care system than one that focuses on the treatment of disease.
It is time for Congress, the health insurance industry and health care providers to join the court and work together to fix the problems of the ACA and develop an alternative to socialized medicine with an effective hybrid system that centers on prevention, wellness and primary care.
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