Supreme Court Strikes Down Third Challenge to Affordable Care Act

The U.S. Supreme Court upheld the Affordable Care Act (ACA) in its 7-2 ruling against the state of Texas and other plaintiffs that challenged the constitutionality of the ACA, saying the plaintiffs had no legal standing to bring the case.

The ruling puts to rest the latest legal challenge to the ACA brought by Republican activists and lawmakers seeking to weaken or invalidate altogether the landmark health care reform signed by President Barack Obama in 2010. In 2012 the court upheld the ACA in National Federation of Independent Business v. Sebelius and again in 2015 in King v. Burwell.

This time the suit, California, et al., v. Texas, et al., was brought by the state of Texas and 19 other states. It revolved around the “severability” of one component of the ACA—the individual mandate, which had required uninsured individuals who did not sign up for health insurance to pay a penalty—from the rest of the law.

In 2017, Congress amended the law to eliminate the penalty associated with the mandate. In light of that, Texas and the other plaintiffs argued that since the individual mandate was a lynchpin of the law, the entire ACA was therefore unconstitutional.

In 2019, APA signed a friend-of-the-court brief rebutting the Texas argument. It drew attention to critical features of the ACA that operated entirely independently of the individual mandate and its penalty: voluntary state Medicaid expansion to 133% of the federal poverty level, provisions prohibiting exclusion from coverage for preexisting conditions, extension of insurance coverage to young adults on their parents’ insurance plans, and coverage of preventive services, among others.

The brief—also signed by the AMA and 18 other medical specialty organizations—asserted that elimination of these provisions under wholesale invalidation of the ACA would “have a devastating impact on patients and the American health care system.”

In its decision, the Supreme Court ruled that the plaintiffs did not have legal standing to bring the case because they had not proved they had been injured by the law. Writing for the majority, Justice Stephen Breyer wrote, “[W]e conclude that the plaintiffs in this suit failed to show a concrete, particularized injury fairly traceable to the defendants’ conduct in enforcing the specific statutory provision they attack as unconstitutional. They have failed to show that they have standing to attack as unconstitutional the Act’s minimum essential coverage provision.

“Therefore, we reverse the Fifth Circuit’s judgment in respect to standing, vacate the judgment, and remand the case with instructions to dismiss.”

The two dissenting justices—Justices Samuel Alito and Neal Gorsuch—argued the plaintiffs do have standing. “The States have clearly shown that they suffer concrete and particularized financial injuries that are traceable to conduct of the Federal Government. The ACA saddles them with expensive and burdensome obligations, and those obligations are enforced by the Federal Government. That is sufficient to establish standing.”

Alito further wrote that the individual mandate was indeed inseverable from the rest of the ACA and that therefore the entire law was unenforceable. And he closed with sardonic remarks about the court’s “rescue” of the ACA.

“No one can fail to be impressed by the lengths to which this Court has been willing to go to defend the ACA against all threats,” he concluded. “A penalty is a tax. The United States is a State. And 18 States who bear costly burdens under the ACA cannot even get a foot in the door to raise a constitutional challenge. So a tax that does not tax is allowed to stand and support one of the biggest Government programs in our Nation’s history. Fans of judicial inventiveness will applaud once again.”

Reena Kapoor, M.D., chair of the APA Committee on Judicial Action, said APA has followed the case closely. “We are pleased about the Supreme Court’s recent ruling,” she said. “Although the basis for the decision was technical, having to do with who has standing to bring this type of legal challenge to the ACA, the result is that millions of people who enrolled in health insurance plans through the ACA will continue receiving necessary mental health care.

“Looking toward the future, we anticipate fewer challenges to the ACA under the Biden administration.  However, since cases can take years to wind their way through the courts, we remain vigilant about further attempts to hold the ACA unconstitutional.”

Marvin Swartz, M.D., a member and past chair of the APA Committee on Judicial Action, told Psychiatric News that numerous studies have documented improved insurance coverage for people with mental illness and substance use disorders under the ACA. “We are hopeful that the decision will put challenges to the ACA behind us and instill further confidence in this cornerstone of equitable and affordable health care.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., praised the court’s ruling. “With more Americans seeking mental health and substance use services, the elimination of coverage would impact millions of Americans,” Levin said. “The court made the right decision. APA will continue to be vigilant about protecting the rights of our patients guaranteed by the ACA.” ■

The Supreme Court ruling in California v. Texas is posted here.

The 2019 amicus brief is posted here.