APA Joins Amicus Brief in Argument Against Texas Ruling Invalidating ACA

APA joined an amicus curiae brief arguing that a U.S. district court decision invalidating the entire Affordable Care Act (ACA) should be reversed, or at least returned to the state for reconsideration.

The amicus brief, signed by APA and four other medical organizations, was filed in the case Texas, et al., v. United States of America, et al., and California, et al. They argue that U.S. District Judge Reed O’Connor of the Northern District of Texas was in error when he concluded last December that the “individual mandate” was struck down as unconstitutional and that, therefore, the entire ACA was thereby invalidated. The individual mandate is a provision within the ACA that requires individuals to purchase health insurance or be assessed a tax; in 2017, Congress eliminated the tax associated with the mandate (though the mandate itself still stands).

The lawsuit was filed last year by a group of Republican governors and state attorneys general. The ruling has no immediate effect and is being appealed by numerous states.

Wholesale invalidation of the ACA would “have a devastating impact on patients and the American health care system,” APA and the four groups argue. They cited a March 2019 Urban Institute analysis (“State-by-State Estimates of the Coverage and Funding Consequences of Full Repeal of the ACA”), which found that if the entire law were eliminated, the number of uninsured people in the United States would rise to 50.3 million people, an increase of 65.4%, or 19.9 million people, and Medicaid and CHIP enrollment would fall by 15.4 million people through the elimination of the ACA’s Medicaid expansion.

The other groups signing on to the brief with APA are the AMA, American College of Physicians, American Academy of Family Physicians, and American Academy of Pediatrics.

Marvin Swartz, M.D., chair of APA’s Committee on Judicial Action, said patients with behavioral health conditions have seen enormous benefits under the ACA that would be undone if the law were ruled unconstitutional. “Notably we have seen very well-documented gains in coverage attributable to Medicaid expansion, elimination of preexisting conditions, and extension of coverage on family policies to age 26,” he said. “Undoing those gains would undermine the gains in health enjoyed by our patients.”

APA President Altha Stewart, M.D., echoed those comments. “I am proud to have worked during my presidential year with leaders of other physician groups to protect the Affordable Care Act from efforts to dilute it or kill it,” she said. “The federal district court decision is wrong and should be overturned. APA will continue to work on behalf of our patients who have benefited from provisions in the ACA.”

The legal question that the amicus brief addresses is the “severability” of one provision in a law that is deemed unconstitutional from every other provision in that law. Last December, O’Connor ruled that since Congress repealed the tax penalty associated with the individual mandate requiring people to have insurance in 2017, the mandate “can no longer be sustained as an exercise of Congress’ tax power” and is therefore unconstitutional (Psychiatric News, December 28, 2018).

O’Connor further argued that the individual mandate cannot be separated—is “inseverable”—from the rest of the law and that the remaining provisions of the ACA are therefore invalid.

Leaving aside the alleged unconstitutionality of the individual mandate, the amicus brief argues that even if it were, it would not invalidate the rest of the law. “When one provision of a statute is held unconstitutional, the remaining provisions are presumed to survive—unless it is evident that Congress intended them to be inseparable and they cannot function independently,” the amicus states.

“Here, the district court improperly discounted congressional intent when, in 2017, Congress zeroed-out the tax on noncompliance with the individual mandate. Likewise, it failed to conduct a comprehensive analysis of whether other ACA provisions remain functional after that change.”

The amicus further states that in eliminating the payment for noncompliance with the individual mandate, Congress clearly intended all other ACA health care provisions to continue in force, including these:

“Nothing indicates that the 2017 Congress intended these provisions to be struck down because the tax on noncompliance with the individual mandate was reduced to zero,” according to the amicus. “Rather, these provisions are fundamental to the delivery of high-quality, affordable care in this country. As leading supporters of the legislation recognized, their invalidation would throw our health care system into chaos and would deprive patients of critical benefits that Congress intended them to have.”

The case is expected to eventually be heard by the U.S. Supreme Court. ■

The amicus brief can be accessed here. The Urban Institute report on consequences of repealing the ACA is available here. The ruling by the U.S. District Court ruling is posted here.