Supreme Court leaves Affordable Care Act intact, but stakeholders say healthcare reform still has a ways to go

• The Affordable Care Act remained the law of the land after a 7-2 Supreme Court ruling that was issued Thursday in California v. Texas.
• Hospital advocates applauded the ruling, saying a decision to overturn the law would have had negative repercussions for both consumers and providers.
• In the wake of the ruling, stakeholders see a continuing need to address the affordability of healthcare.

The Supreme Court on Thursday upheld the Affordable Care Act (ACA) for a third time, further ingraining the law as a permanent fixture like Medicare and Medicaid.

In a 7-2 ruling, the court said Republican-led states did not have standing to challenge the 2010 law. The basis for the suit stemmed from Congress’s 2017 decision to nullify the penalty for not having health insurance. The plaintiffs had argued that the change rendered the law unconstitutional.

Healthcare stakeholders across the industry expressed support for Thursday’s decision. Hospital groups have backed the law since its inception, especially provisions designed to encourage people to be covered through either the ACA insurance marketplaces or expanded Medicaid programs.

In a January 2020 amicus brief, five leading hospital groups referred to “the catastrophic consequences that would follow from judicial repeal of the ACA.”

“It would cause millions of Americans to lose their health coverage, inflicting on them all the harms that come with being uninsured. Low-income families, those least able to cope with these harms, would be hardest hit,” the groups wrote.

A different ruling would have hampered providers

The ACA’s coverage expansion was funded in part by reductions to annual increases in Medicare payments to providers. Hospital advocates accepted those provisions during the legislative process because covering more people theoretically would boost the health of communities and also because of the financial benefits to be gained by decreasing the uninsured rate.

In the improbable event that the law had been overturned in the latest case, hospitals still would be receiving smaller Medicare payments but without the advantages of more-expansive coverage.

“Such a finding would also have severe consequences for the hospitals and physicians that provide care to all Americans, which would be forced to shoulder a greater uncompensated-care responsibility,” the hospital groups wrote in the amicus brief.

The ACA represents an expansion of the commercial insurance market (and of Medicaid). Provider groups generally prefer that approach to the prospect of a large expansion of government-sponsored insurance, which likely would usher in lower payment rates and make sustainability of operations a more pressing concern.

For example, when Democratic congressional leaders in May requested stakeholder feedback on adding a public option to the ACA marketplaces, the American Hospital Association (AHA) sent out a statement opposing the idea within a few hours.

“We do not support the introduction of a public option plan that could increase the strain COVID-19 has placed on our healthcare system,” AHA President and CEO Rick Pollack said in the statement. “This type of proposal would strip significant resources from providers by relying on inadequate reimbursement rates, increasing the risk of hospital closures and threatening access to care for patients and communities.”

Healthcare reform is far from finished

The White House has been promoting recent enrollment increases following the passage in March of COVID-19 relief legislation that expanded the availability of subsidies for purchasing insurance in the ACA marketplaces. More than 31 million are insured through the ACA, and over 1.2 million have signed up for insurance since the start of a six-month special enrollment period Feb. 15.

But as of 2019, there were still 28.9 million people without insurance, corresponding to an uninsured rate of 10.9%, according to data compiled by the Kaiser Family Foundation. One factor in the lingering coverage gap is the continuing hesitation of 12 states to expand Medicaid as authorized by the ACA.

Regardless of coverage expansions, critics say the law does not improve the affordability of healthcare and leaves many people with thin coverage and high out-of-pocket costs.

“Today’s ruling reminds us that Congress needs to return to health reform,” Kay C. James, president of the conservative Heritage Foundation, said in a statement. “Many Americans still need relief from the rising healthcare costs and shrinking coverage options that have resulted from the Affordable Care Act.”

Building a system to address those issues in the absence of the ACA would have been daunting, but stakeholders say much work remains even with the law still in place.

“The more than 30 million Americans who secured health insurance under the Affordable Care Act can again breathe a sigh of relief,” Pollack said in a statement released Thursday. “But our work is far from over. We need to redouble our efforts to close coverage gaps and make care affordable and accessible for everyone, all while continuing to fight COVID-19 and encouraging more Americans to get vaccinated.”

On the insurance side, the head of the Blue Cross Blue Shield Association voiced similar sentiments.

“Today’s decision now gives the nation an opportunity to meaningfully tackle the underlying cost of healthcare — one of the most critical challenges in the healthcare system,” Kim Keck, president and CEO of BCBSA, said in a statement.

“As we’ve seen throughout the COVID-19 pandemic, it’s more important than ever that everyone has access to affordable healthcare, no matter who you are, where you live or what your health condition may be. It’s time to build on what we have to make our healthcare system more affordable and equitable to work better for everyone.”