The U.S. Supreme Court on Thursday for the third time upheld the Affordable Care Act, the federal law under which more than 500,000 Georgians buy subsidized health insurance and millions more are assured mandated health benefits on private plans, including coverage of pre-existing conditions, emergency room visits and prescriptions.
The justices, by a 7-2 vote, left the entire law intact and ruled that Texas, Georgia and other GOP-led states as well as two individuals had no legal right to bring their lawsuit in federal court. The decision preserves health insurance coverage for millions of Americans.
Advocates both for and against the ACA said the ruling may mark the last broad challenge to the law’s existence and turn the focus to what action state legislators and governors can take to address its perceived shortcomings.
For Georgia, that means a focus on people who are poor and uninsured, and whether to expand Medicaid to them under the ACA or fight for a conservative “waiver” program that would insure some of them if they meet certain requirements.
Georgia is among 12 states that did not expand Medicaid to all poor adults, and remains third-worst in the nation for its portion of uninsured residents, behind only Texas and Oklahoma.
The Rev. Jill Henning, a cancer survivor who lives in Grayson and has become an advocate for the ACA, said if the court struck down the ACA, insurance companies would likely have dropped her cancer coverage as a pre-existing condition, and left her wondering if she’d lose her house to pay for the high-tech scans she needs every three months.
“It’s been a decade of just wondering and waiting to see what was going to take place, and what was going to mean for us in the long run,” Henning said.
Credit: Alyssa Pointer / Alyssa.Pointer@ajc.com
Credit: Alyssa Pointer / Alyssa.Pointer@ajc.com
The ACA also eliminated lifetime caps on insurance coverage. No matter how much Henning’s screenings and treatments cost over her lifespan — the cancer returned four years ago, fought back by chemotherapy— she won’t reach a cap. “Today’s a great day for me,” she said.
State Attorney General Chris Carr, who joined Georgia to Texas’ effort to strike down the law, said in a statement that he was disappointed but would respect the court’s decision.
“Our coalition felt strongly that the ACA was unconstitutional,” Carr said. “I stand by my pledge to ensure we have the world-class health care system that all Georgians and our nation truly deserve.”
The ruling
The law made fundamental changes in health care for Americans, far beyond those shopping for insurance on the ACA exchange or those with pre-existing conditions. It forced insurance policies to accept policyholders’ children on their parents’ plans until the age of 26. It also closed a “donut hole” in Medicare drug coverage. Such provisions were popular but also made the law a target among conservatives who saw them as overreach.
Yet Thursday’s ruling was a surprise for some because the court’s nine justices now include three appointed by President Donald Trump, creating a solid overall conservative majority.
In the ruling, the justices relied on those same conservative legal principles to dismiss the suit, deciding the court had a duty to stay out of Congress’ way.
Those attacking the ACA had argued that the provision that made it possible as a federal law was the financial penalty people have to pay if they failed to get insured. The court ruled in the first challenge, in 2012, that Congress had the right to impose the law because it has the power to tax.
But Republicans in Congress had reduced the penalty to $0 in 2017, in an effort to make the law toothless. So the plaintiffs in the latest suit argued that since the penalty was now zero, it effectively didn’t exist, and so the whole law had to collapse.
The justices, however, ruled that they had no business getting involved and issuing theoretical opinions since the plaintiffs weren’t harmed by the penalty and didn’t need any money back.
“The matter is not simply technical,” Justice Stephen Breyer wrote for the majority. “To find standing here …would threaten to grant unelected judges a general authority to conduct oversight of decisions of the elected branches of Government.”
Georgia native Justice Clarence Thomas agreed. Justices Neil Gorsuch and Samuel Alito dissented.
What now
Both supporters and opponents of the ACA Thursday were quick to turn to next steps. Supporters have argued for years that the law needs fixing in Congress, but say they were foiled by opponents who wanted to see it fail. Opponents said Congress needed to repeal and replace it, although Republicans have never presented a replacement proposal that could muster support.
The law’s gaps are widely agreed on. Under the law, adults who make below the poverty level, or $12,880 per year in income for a single person, are not necessarily covered unless a state opts to expand Medicaid to all of its poor. If it does so under the ACA, the federal government pays 90% of the Medicaid costs.
People earning above the poverty level get subsidies for their premiums, but they wane as the income level goes higher. There are no subsidies for those with incomes at four times the poverty level or higher. That leaves an individual making $51,520 or more, or a family of four making $106,000 or more, to pay the full price premiums, plus deductibles that can be several thousand dollars annually.
Chris Denson, director of policy and research at the libertarian-leaning Georgia Public Policy Foundation, said the ruling “pretty much means that the ACA is going to remain in place.” But he said the ACA fails to address the soaring cost of health care.
Georgia Gov. Brian Kemp has proposed two state-centered “waivers” to deal with some of those gaps. One would help Georgia policyholders with higher incomes by helping to lower premium costs generally, through large state subsidies. It would also block Georgians’ access to shopping on the ACA marketplace website, healthcare.gov.
Another of Kemp’s waiver proposals is meeting with hesitation in the Biden administration: It would address the uninsured poor adults, aiming to expand Medicaid to those who perform a certain amount of specific activities each month. Perhaps 50,000 Georgians would end up qualifying, compared to more than 400,000 likely to qualify for full Medicaid expansion, according to estimates by Kemp’s office.
Not everyone is convinced the fundamental threats to the ACA are over.
John Haupert, CEO of Grady Health System, said “thank goodness” the lawsuit failed, but noted the court left it open for other plaintiffs to figure out how they might sue. Grady has financial counselors to help people figure out if they’re eligible for coverage on the ACA marketplace.
Steven Ledbetter, of Athens, said Thursday he was glad he still has insurance to keep paying for his insulin as well as checkups to his eyes and feet as he deals with diabetes.
Ledbetter works a number of jobs, like teaching music to disabled students for a nonprofit organization, to cobble together about $24,000 a year. With his subsidies from the ACA exchange, his insurance premiums are $15 per month, a price he can afford.
“The peace of mind means a tremendous amount,” he said.
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