World Report
US Supreme Court upholds ACA subsidies Last week’s landmark ruling on the Affordable Care Act helps more than 6 million Americans pay for health insurance. The Lancet’s Washington correspondent, Susan Jaffe reports. Although critics still deride it as Obamacare, President Barack Obama’s Supreme Court victory last week enshrined the Affordable Care Act (ACA) as one of his greatest domestic accomplishments. The court might have also effectively disarmed the opposition, shifting the debate to next year’s campaign for the presidency as the next chance for critics to try to dismantle the law. But for 6·4 million Americans who could have lost the health law’s insurance subsidies—the key issue before the court—the historic ruling has a different meaning. “Thank God, I can still get my medical care”, said Jacqueline Clay, a New Jersey woman receiving treatment for breast cancer who turned 61 years of age the day the court upheld the subsidies. “I am not going to die.” Clay lost her health insurance when she lost her job and has not been able to work because of her illness. She receives financial assistance that pays for two-thirds of the monthly premium for her ACA health insurance. Doctors recently removed a cancerous tumour from her colon. “If I need
to continue chemotherapy, I am covered”, she said. New Jersey is one of 34 states, most with Republican governors who oppose the ACA, that did not set up their own internet-based health insurance exchanges, a quasigovernmental system created by the law in which private insurance companies can sell policies that meet minimum standards, and low-income beneficiaries can receive subsidies to purchase coverage. The federal government stepped in to run the exchanges for states that declined to do so.
“If the court had agreed to block the federal exchange subsidies... government lawyers argued that the health law would have slowly unravelled...” David King and three other Virginia residents sued Sylvia Burwell Matthews, Secretary of the US Department of Health and Human Services, to block subsidies in their state and others with federally run exchanges, claiming that the law
Bloomberg
See Editorial page 2
ACA supporters celebrate outside the Supreme Court following the judgment on June 25
16
limits subsidies to policies purchased through state-operated exchanges. Of the roughly 10·2 million Americans receiving coverage through the exchanges, 8·7 million receive financial help paying their monthly insurance premiums, including 6·4 million in the federally run exchange. If the court had agreed to block the federal exchange subsidies, worth about US$1·7 billion a month, government lawyers argued that the health law would have slowly unravelled, starting with millions of Americans being unable to afford their insurance.
An essential part of the law In a six to three vote decision, Chief Justice John Roberts wrote for the majority (including Justices Anthony Kennedy, Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, and Elena Kagan) that the law’s subsidy language was among several “inartful” provisions. Although it was ambiguous, he said this provision should be read in the context of the overall law. Provided in the form of tax credits, the subsidies are one of three interlocking reforms of the law, Roberts wrote, along with the mandate that most adults have insurance and the requirement that insurers not turn away people who want to purchase coverage or charge them higher prices on the basis of age or pre-existing health conditions. Roberts cited reports that nearly 87% of people who bought insurance through the federally run exchange received subsidies in 2014. Since the subsidies are an essential part of the law’s reforms, Roberts said, it was “implausible” that Congress intended to limit subsidies only to staterun exchanges. “In every case, we must respect the role of the Legislature, and take care not to undo what it has done. A fair reading of legislation demands www.thelancet.com Vol 386 July 4, 2015
World Report
a fair understanding of the legislative plan”, he wrote. “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them”, he concluded. Justice Antonin Scalia, writing the dissenting opinion (and joined by Justices Clarence Thomas and Samuel Alito), called such reasoning “absurd”, “eccentric”, and “interpretive jiggerypokery.” The subsidy provision is clear, he wrote. “Reading the Act as a whole leaves no doubt about the matter: ‘Exchange established by the State’ means what it looks like it means”, Scalia wrote. He accused the Chief Justice of rewriting the law to save it. Referring to the Supreme Court of the United States by its acronym, he wrote, “We should start calling this law SCOTUScare.”
“Here to stay” President Obama welcomed the Roberts decision as an affirmation of something much more than the subsidies. “After more than 50 votes in Congress to repeal or weaken this law, after a presidential election based in part on preserving or repealing this law, after multiple challenges to this law before the Supreme Court, the Affordable Care Act is here to stay”, he told reporters gathered at the White House shortly after the court released its ruling. “We finally declared that in America health care is not a privilege for a few but a right for all”, he said. He also felt compelled to explain what the law does for an American public that opinion polls show is still divided along political lines on the law 1·5 years after implementation. It allows adult children to remain on their parents’ plan until they are 26 years old, the president noted. It prohibits insurers from charging women higher rates than men, bans annual limits on coverage, and requires policies to include free preventive health services such as mammograms. And it forbids insurers from discriminating against people with pre-existing health conditions by raising their premiums or even refusing www.thelancet.com Vol 386 July 4, 2015
to sell them a policy. “That affects everybody with health insurance, not just folks who got insurance through the Affordable Care Act”, Obama said. But Obama did not feel obliged to mention two of the law’s most controversial provisions that require most adults to buy health insurance and most large employers to provide insurance. Failure on either measure can result in penalties.
“‘...for all the misinformation campaigns and all the doomsday predictions and the talk of death panels and job destruction and the repeal attempts, this law is now helping tens of millions of Americans.’” Republican congressional leaders reacted to the court decision by reiterating their criticism of the law. “Obamacare is fundamentally broken”, said John Boehner, the Republican majority leader of the US House of Representatives. “It is raising costs for people, it is pushing people out of the ability to afford health insurance, and it needs to be dealt with.” Yet he acknowledged the obstacle opponents face: “It is very difficult to deal with it when you have a president that fundamentally disagrees with us. And so the struggle will continue.” Although there are various legislative strategies that the Republicans could use to try to chip away at the health law by gathering sufficient votes to overcome the president’s veto, the chance of success is small, Tom Miller, resident fellow at the American Enterprise Institute, told The Lancet. “The president has the high cards”, he said. “It’s a lot of trouble for the Republicans to do anything but symbolic votes.” Miller expects some incremental changes in the law, such as removing a tax on medical devices. “In a practical, tangible sense this is locked up until 2017”, he said, when a new president moves into the White House. How the law will be affected depends on “how
clear cut the presidential race frames this and whether or not people vote in a direction that signals anything”, he said.
Time to fine tune Some supporters of the law hope there will now be an opportunity to make some improvements. “The court decision frees us up to work on the next stage”, Lynn Quincy, associate director for health policy at Consumers Union, told The Lancet. Among the things that need attention are helping more states participate in the law’s expansion of Medicaid, the healthcare programme for low-income families. So far, 21 mostly Republicandominated states have not expanded Medicaid, even though the law requires the federal government to pay 100% of the cost next year and 90% thereafter. As a result, millions of Americans “don’t have a good affordable coverage option”, said Quincy. “States have a lot of flexibility about how they get across the finish line.” Supporters would also like to focus on improving health care value and quality, which Obama also mentioned among the next steps needed “to make health care in America even better”. Although he admitted “we have more work to do”, he also claimed that the law was working. “The point is, this is not an abstract thing anymore. This is not a set of political talking points. This is reality... for all the misinformation campaigns and all the doomsday predictions and the talk of death panels and job destruction and the repeal attempts, this law is now helping tens of millions of Americans.” Jacqueline Clay said she is one of them. “I am the person I think Obama was thinking of. I have worked all my life and have had good jobs but to find out at this point in my life that there was a chance I would have no health coverage—that this country is not going to help me—is absolutely terrible. Without the ACA, I don’t know where I would be.”
Susan Jaffe 17
US Supreme Court upholds ACA subsidies Last week’s landmark ruling on the Affordable Care Act helps more than 6 million Americans pay for health insurance. The Lancet’s Washington correspondent, Susan Jaffe reports. Although critics still deride it as Obamacare, President Barack Obama’s Supreme Court victory last week enshrined the Affordable Care Act (ACA) as one of his greatest domestic accomplishments. The court might have also effectively disarmed the opposition, shifting the debate to next year’s campaign for the presidency as the next chance for critics to try to dismantle the law. But for 6·4 million Americans who could have lost the health law’s insurance subsidies—the key issue before the court—the historic ruling has a different meaning. “Thank God, I can still get my medical care”, said Jacqueline Clay, a New Jersey woman receiving treatment for breast cancer who turned 61 years of age the day the court upheld the subsidies. “I am not going to die.” Clay lost her health insurance when she lost her job and has not been able to work because of her illness. She receives financial assistance that pays for two-thirds of the monthly premium for her ACA health insurance. Doctors recently removed a cancerous tumour from her colon. “If I need
to continue chemotherapy, I am covered”, she said. New Jersey is one of 34 states, most with Republican governors who oppose the ACA, that did not set up their own internet-based health insurance exchanges, a quasigovernmental system created by the law in which private insurance companies can sell policies that meet minimum standards, and low-income beneficiaries can receive subsidies to purchase coverage. The federal government stepped in to run the exchanges for states that declined to do so.
“If the court had agreed to block the federal exchange subsidies... government lawyers argued that the health law would have slowly unravelled...” David King and three other Virginia residents sued Sylvia Burwell Matthews, Secretary of the US Department of Health and Human Services, to block subsidies in their state and others with federally run exchanges, claiming that the law
Bloomberg
See Editorial page 2
ACA supporters celebrate outside the Supreme Court following the judgment on June 25
16
limits subsidies to policies purchased through state-operated exchanges. Of the roughly 10·2 million Americans receiving coverage through the exchanges, 8·7 million receive financial help paying their monthly insurance premiums, including 6·4 million in the federally run exchange. If the court had agreed to block the federal exchange subsidies, worth about US$1·7 billion a month, government lawyers argued that the health law would have slowly unravelled, starting with millions of Americans being unable to afford their insurance.
An essential part of the law In a six to three vote decision, Chief Justice John Roberts wrote for the majority (including Justices Anthony Kennedy, Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, and Elena Kagan) that the law’s subsidy language was among several “inartful” provisions. Although it was ambiguous, he said this provision should be read in the context of the overall law. Provided in the form of tax credits, the subsidies are one of three interlocking reforms of the law, Roberts wrote, along with the mandate that most adults have insurance and the requirement that insurers not turn away people who want to purchase coverage or charge them higher prices on the basis of age or pre-existing health conditions. Roberts cited reports that nearly 87% of people who bought insurance through the federally run exchange received subsidies in 2014. Since the subsidies are an essential part of the law’s reforms, Roberts said, it was “implausible” that Congress intended to limit subsidies only to staterun exchanges. “In every case, we must respect the role of the Legislature, and take care not to undo what it has done. A fair reading of legislation demands www.thelancet.com Vol 386 July 4, 2015
World Report
a fair understanding of the legislative plan”, he wrote. “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them”, he concluded. Justice Antonin Scalia, writing the dissenting opinion (and joined by Justices Clarence Thomas and Samuel Alito), called such reasoning “absurd”, “eccentric”, and “interpretive jiggerypokery.” The subsidy provision is clear, he wrote. “Reading the Act as a whole leaves no doubt about the matter: ‘Exchange established by the State’ means what it looks like it means”, Scalia wrote. He accused the Chief Justice of rewriting the law to save it. Referring to the Supreme Court of the United States by its acronym, he wrote, “We should start calling this law SCOTUScare.”
“Here to stay” President Obama welcomed the Roberts decision as an affirmation of something much more than the subsidies. “After more than 50 votes in Congress to repeal or weaken this law, after a presidential election based in part on preserving or repealing this law, after multiple challenges to this law before the Supreme Court, the Affordable Care Act is here to stay”, he told reporters gathered at the White House shortly after the court released its ruling. “We finally declared that in America health care is not a privilege for a few but a right for all”, he said. He also felt compelled to explain what the law does for an American public that opinion polls show is still divided along political lines on the law 1·5 years after implementation. It allows adult children to remain on their parents’ plan until they are 26 years old, the president noted. It prohibits insurers from charging women higher rates than men, bans annual limits on coverage, and requires policies to include free preventive health services such as mammograms. And it forbids insurers from discriminating against people with pre-existing health conditions by raising their premiums or even refusing www.thelancet.com Vol 386 July 4, 2015
to sell them a policy. “That affects everybody with health insurance, not just folks who got insurance through the Affordable Care Act”, Obama said. But Obama did not feel obliged to mention two of the law’s most controversial provisions that require most adults to buy health insurance and most large employers to provide insurance. Failure on either measure can result in penalties.
“‘...for all the misinformation campaigns and all the doomsday predictions and the talk of death panels and job destruction and the repeal attempts, this law is now helping tens of millions of Americans.’” Republican congressional leaders reacted to the court decision by reiterating their criticism of the law. “Obamacare is fundamentally broken”, said John Boehner, the Republican majority leader of the US House of Representatives. “It is raising costs for people, it is pushing people out of the ability to afford health insurance, and it needs to be dealt with.” Yet he acknowledged the obstacle opponents face: “It is very difficult to deal with it when you have a president that fundamentally disagrees with us. And so the struggle will continue.” Although there are various legislative strategies that the Republicans could use to try to chip away at the health law by gathering sufficient votes to overcome the president’s veto, the chance of success is small, Tom Miller, resident fellow at the American Enterprise Institute, told The Lancet. “The president has the high cards”, he said. “It’s a lot of trouble for the Republicans to do anything but symbolic votes.” Miller expects some incremental changes in the law, such as removing a tax on medical devices. “In a practical, tangible sense this is locked up until 2017”, he said, when a new president moves into the White House. How the law will be affected depends on “how
clear cut the presidential race frames this and whether or not people vote in a direction that signals anything”, he said.
Time to fine tune Some supporters of the law hope there will now be an opportunity to make some improvements. “The court decision frees us up to work on the next stage”, Lynn Quincy, associate director for health policy at Consumers Union, told The Lancet. Among the things that need attention are helping more states participate in the law’s expansion of Medicaid, the healthcare programme for low-income families. So far, 21 mostly Republicandominated states have not expanded Medicaid, even though the law requires the federal government to pay 100% of the cost next year and 90% thereafter. As a result, millions of Americans “don’t have a good affordable coverage option”, said Quincy. “States have a lot of flexibility about how they get across the finish line.” Supporters would also like to focus on improving health care value and quality, which Obama also mentioned among the next steps needed “to make health care in America even better”. Although he admitted “we have more work to do”, he also claimed that the law was working. “The point is, this is not an abstract thing anymore. This is not a set of political talking points. This is reality... for all the misinformation campaigns and all the doomsday predictions and the talk of death panels and job destruction and the repeal attempts, this law is now helping tens of millions of Americans.” Jacqueline Clay said she is one of them. “I am the person I think Obama was thinking of. I have worked all my life and have had good jobs but to find out at this point in my life that there was a chance I would have no health coverage—that this country is not going to help me—is absolutely terrible. Without the ACA, I don’t know where I would be.”
Susan Jaffe 17
