The Supreme Court’s forceful 6 to 3 opinion upholding a key provision of the Affordable Care Act is now in place. Obamacare is settled law. “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” Chief Justice John Roberts wrote for the majority. And in doing so, his court has handed down a decision that is a devastating blow to ideological opponents of universal health care and solidifies a fundamental new deal between Americans and our government.
As a doctor who focuses on cases of catastrophic injuries, where my patients have frequently seen their incomes change and the insurance they once had run out or become unaffordable (or unavailable with a “pre-existing” condition), today’s ruling represents an enormous relief. I’ve long been a supporter of Obamacare, because I know how important it is for my patients.
The court saw through the plaintiff’s thin claims, which rested on a line in the Affordable Care Act. When read literally, the line implies that only state-based insurance exchanges can supply applicants with the necessary tax credits to make insurance affordable. As the court pointed out, the law must be read as a whole document, and when you do that, the actual meaning is clear.
Roberts specifically cited a passage where the law calls for the federal government to stand in for the states and establish “such exchange” if a state does not do so. Much of the law simply makes no sense read any other way, such as its careful directions that all exchanges, whether state or federal, serve qualified individuals. In the plaintiff’s view, there are no qualified individuals in any of the states where federal exchanges operate, the Supreme Court pointed out.
True, Obamacare didn’t escape the Supreme Court without criticism. The court pointed out that the rushed legislative process led to “inartful” drafting. For example, almost comically, the ACA contains three sections labeled the same: “Section 1563.”
But nobody looks to the law for art, even if a Supreme Court justice might wish it so. It’s all about the function, and in that sense, the ACA is clear.
The court carefully outlined the law’s lineage back to a particularly fertile laboratory of democracy, Massachusetts, which birthed the law’s three “interlocking” features of an insurance mandate, open insurance markets and tax credits. If the ACA is the direct descendent of that state’s universal health care plan (which brought the uninsured rate down to 2.6%), then it’s absurd to think that the law’s drafters intentionally unlocked any of these interlocking policies.
Without tax credits, there’s no effective insurance mandate, because the insurance rates will often exceed the 8% income limit prescribed in the law, leaving the law’s three-legged stool without two of its legs. Moreover it doesn’t do much good to require community-priced insurance that’s open to everyone regardless of pre-existing conditions if people can’t afford it.
But it’s the law’s very name – the Affordable Care Act — that was perhaps the best uncited evidence that the case was a hopeless Hail Mary pass from the start.
In his ppinion piece for CNN, Wisconsin Gov. Scott Walker argued vehemently that if the court overturned the ACA, the ball would be in the President’s court. He insisted that it would be the President’s responsibility to repeal and replace the ACA. This is rich stuff when you consider that Walker and other Republican governors stood in the door against Medicaid expansion and refused to do anything to help the law deliver insurance access in their states.
Walker should reflect on how lucky he is that the court didn’t rule his way, because he and other Republican governors would have found themselves under enormous pressure as millions of Americans lost their insurance coverage.
With two Supreme Court rulings upholding the law, the dynamics of the 2016 presidential election are changing, and the debate can no longer be about flawed or unconstitutional legislation. What’s more, Republicans like Walker can’t now simply sit back and cheer in the hopes that the Supreme Court would do their will while defraying the blame as a dismantled law leaves Americans uninsured. The days when the Republicans could try to claim some kind of moral authority about the ACA’s alleged evils have surely been banished by this emphatic decision.
The problem for the Republicans now is that their all-in support of the King v. Burwell challenge means the party has lost the chance to influence discussion of what is now a major function of our government. Whether federal or state, a major part of the job for our policymakers — and wannabe leaders — is ensuring access to quality, affordable health care. By backing this failed effort, they have missed a real opportunity to contribute meaningfully.
Ultimately, the ACA joins Medicare itself in the pantheon of American progress. Attempting to repeal the ACA, even under a future Republican president and Congress, is now as unthinkable as repealing Medicare itself. This is an important day for my patients, past and future.