Our Year in Review series highlights some of the major medical news stories of 2015. On the policy front, the year's biggest news was the Supreme Court decision upholding the Affordable Care Act's health insurance exchanges. Here is the original article on the decision, published on June 25th. In a companion article, we report on what has happened since.
WASHINGTON -- The Supreme Court that people who buy insurance through the Affordable Care Act's (ACA's) federally run insurance exchange can continue to receive subsidies to help pay their premiums.
"Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them," the majority concluded. "If at all possible we must interpret the Act in a way that is consistent with the former, and avoids the latter. Section 36B can fairly be read consistent with what we see as Congress's plan, and that is the reading we adopt."
The decision means that 6 to 9 million Americans, whose subsidies were at risk, can trust that their premiums will not spike dramatically. , along with justices , , , , and voted in favor of upholding the subsidies, while justices , , and filed a dissenting opinion.
Scalia Scornful
In the courtroom, Scalia, who wrote the dissent, said that under "all the usual rules of interpretation" the government should have lost the case. He called the majority's interpretation an "eccentric reading" of the law.
"The Secretary of Health and Human Services is not a state, so an exchange established by the secretary is not an exchange established by the state," he said.
In King v. Burwell, the plaintiffs, four Virginia residents, argued that they are not eligible for subsidies according to a technical formula written into the law to calculate the cost of individuals' premiums. The problem, they claimed, is that the provision -- known as 36B -- only refers to tax subsidies in exchanges "established by the state." In Virginia and 33 other states, the health insurance exchanges are run by the federal government, because these states never developed their own exchanges.
"Petitioners' arguments about the plain meaning of Section 36B are strong," the justices, led by Roberts, wrote for the majority. Quoting phrases from another relevant case, they added, "But while the meaning of the phrase 'an exchange established by the State'... may seem plain 'when viewed in isolation,' such a reading turns out to be 'untenable in light of [the statute] as a whole.'"
In the courtroom Thursday, Roberts said that it was "implausible" that Congress meant the act to be interpreted in the manner that the plaintiffs described. "Our role is limited ... we must respect the role of the legislature," he said. "A fair reading of the legislation means a fair understanding of the legislative plan."
In the decision, the majority noted that the structure of the provision in question "suggests that tax credits are not limited to State Exchanges" since they provide for subsidies, in the form of tax credits, to be given to any "applicable taxpayer. "An "applicable taxpayer" is then defined as someone with a specified household income. "Together, these two provisions appear to make anyone in the specified income range eligible to receive a tax credit."
In their dissent, justices Scalia, Thomas, and Alito argued that that "words no longer have meaning if an Exchange that is not established by the State is 'established by the State.' ... Under all the usual rules of interpretation, in short, the Government should lose this case. But normal rules of interpretation seem always to yield to the overriding principle of the present Court: The Affordable Care Act must be saved."
The dissenting justices also pointed out six other instances in the ACA in which the words "Exchange established by the State" appear. "It is bad enough for a court to cross out 'by the State' once. But seven times?" they asked.
"The Act that Congress passed makes tax credits available only on an 'Exchange established by the State," the dissenters concluded. "The Court, however, concludes that this limitation would prevent the rest of the Act from working as well as hoped. So it rewrites the law to make tax credits available everywhere. We should start calling this law SCOTUScare" -- a reference to a common abbreviation for the Supreme Court of The United States.
Obama Claims Victory
President Obama cheered the decision. "Today is a victory for hardworking Americans all across this country whose lives will continue to become more secure in a changing economy because of this law," the president said during brief remarks in the White House Rose Garden. "Today, 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."
The American Medical Association also praised the court's decision. "The American Medical Association is relieved that today's Supreme Court decision will allow millions of patients to continue accessing the healthcare they need and deserve," AMA President , said in a statement.
"The subsidies upheld today help patients afford health insurance so they can see a doctor when they need one and not have to wait until a small health problem becomes a crisis. ... With this case now behind us, we hope our country can move forward and continue strengthening our nation's health care system."
The American College of Obstetricians and Gynecologists (ACOG) also applauded the decision. "The goal of the ACA was to improve the health of all Americans by improving access to reliable insurance coverage," ACOG president , said in a statement. "As the physicians who treat America's women, we are pleased that today's Supreme Court decision will protect that access in the future and will allow us to continue our shared mission of keeping America healthy."
, a professor in the department of health policy and management at Emory University, in Atlanta, noted that the court majority, "while acknowledging that the plaintiffs had a 'strong' argument, found that the [Internal Revenue Service's] interpretation was consistent with other sections of the law and its overall purpose."
"If Republicans want to repeal or substantially revise the ACA, they will have to work through the legislature," Howard said in an email to 乌鸦传媒. "Given the divisions within the Republican ranks, I don't foresee any changes in the next few years."
Indeed, the ruling means "that's really it for the Republicans in Congress when it comes to health policy for the rest of the term," said , scholar in healthcare and retirement policy at the American Enterprise Institute, a right-leaning think tank here. "There are certainly no more must-pass bills directed related to health policy -- the physician payment fix was the last one."
Antos suggested that "This ruling actually gives the right of the Republican Party even more influence in the sense that ... you can interpret the ruling as saying to Republicans, 'If you want to change anything, you've just got to repeal the bill.' They've been arguing for a clean repeal, now there will probably be a few more votes on it, and that's going to be 100% of the action on health policy other than not very substantive talk in the campaigns. We'll have to wait for the next president to see anything happen.
, professor of public health policy and management at the University of Arizona, in Tucson, said he wasn't surprised by the ruling. "It's pretty much the way I saw things happening from ... the questions Roberts asked" during oral arguments, he said in a phone interview. "And with Kennedy, it seemed clear he was going to vote [to uphold the subsidies]."
"When I read through the ACA, it seemed clear to me what the intent was," he continued. "If you focus on one statute in isolation it might seem ambiguous, but Chief Justice Roberts laid out very clearly what the intent was when the statute was interpreted as a whole."
, an economist and senior fellow at Project Hope in Bethesda, Md., and former administrator of what is now the Centers for Medicare and Medicaid Services, said that the decision "is obviously less disruptive than it would have been had the Supreme Court ruled against the law," and it means that any changes in the ACA are "likely to come through the congressional process, which is normally the way legislation is best changed."
No Shortage of Opinions
, senior counsel at the left-leaning Constitutional Accountability Center here, called the decision "an absolute and total vindication of the administration's position. ... The message is strong that six members of the court have no interest in contrived legal challenges to the ACA that are designed to turn it upside down."
As for the dissenting opinion, Lazarus said that Scalia has frequently written on statutory interpretation and always stresses the importance of context. "He totally violated his own principles with this interpretation."
, professor of health policy and management, the Johns Hopkins Bloomberg School of Public Health, said the court "restored a bit of faith that not all judicial decisions in the high court are simply a matter of 'red' or 'blue' law. ... This outcome makes it abundantly clear there is no turning back on the biggest advance in healthcare access for American in 5 decades. Maybe now a few of the many holdout governors and legislatures will see the light and expand Medicaid in their states."
, director of the health reform program at Boston University, said in an email that the U.S. "wastes time and energy in dealing with little challenges, often ones that result from self-inflicted injuries -- political or economic. The recently-resolved Medicare sustainable growth rate (SGR) challenge was allowed to persist for a dozen years, wasting energy and political oxygen.
"Happily, the Supreme Court today voted 6-3 to obviate still more unnecessary waste. ... We can all hope that the nation can put behind us the controversy over a technical glitch in the wording of one section of the ACA, and move on to confronting and overcoming the large challenges that we face."
He added that "It's worth noting that the Republican Party dodged a negative as well. Had the Supreme Court struck down subsidies ... and had 6.5 million people consequently lost health insurance coverage, the backlash against Republican elected officials in some states might have been substantial."
, senior vice president at the Bipartisan Policy Center here, agreed that "Republicans may not admit to it but they're breathing a lot easier with this decision ... This will make it a lot easier for congressional Republicans to pass a reconciliation bill that comes close to repealing the entire act as opposed to just a subset."
After repeal efforts have been tried -- and if they fail -- Congress can then work on amending the law "and that's when the negotiations become a little more serious and honest," he added. "This is a kabuki dance, but it keeps moving forward."
A flood of people and organizations weighed in with their opinions on the decision. A few excerpts:
Association of American Medical Colleges: "The ACA is an important step toward an improved healthcare system with greater access to care. Preserving subsidies for affordable coverage will go a long way to ensuring that all Americans can get the healthcare they need."
Physicians for a National Health Program: "The decision must be welcomed [but] the unfortunate reality is that the ACA, despite its modest benefits, is not a remedy to our healthcare crisis: it will not achieve universal coverage ... it will not make healthcare affordable to Americans with insurance ... and it will not control costs."
: "I am deeply disappointed that the Supreme Court did not stop this statute from being used beyond its constitutional boundaries ... I still believe that the president broke the law -- plain and simple. I remain fully committed to preventing [the law's] further disruption in the health market, creating more freedom for states and patients to avoid federal health mandates, and replacing its most egregious intrusions into the doctor-patient relationship."
American Academy of Family Physicians: "By ruling that federal exchange insurance plans qualify for premium subsidies, the Court has ensured that middle- and low-income families can afford the insurance that provides access to comprehensive health services. ... Family physicians across the country applaud the Supreme Court's decision and the health security it brings."
Center for American Progress: "This should be the final nail in the coffin of repeal by legislative and judicial means from opponents of the ACA. It is past time to move on and stop begrudging the healthcare received by millions of their fellow Americans."
Heritage Foundation: "The court decision is a disappointment for the rule of law and for the states that have fought to keep Obamacare's flawed policies out of their states. ... The Supreme Court ruling does not fix Obamacare. The only fix to Obamacare is its repeal."
Committee of Interns and Residents: "[The decision] is a victory both for patients and for healthcare providers. ... We call upon members of Congress to end the divisive, partisan feud over this law that has already made a positive difference in the lives of millions of Americans. We also call on state legislators and governors who have expected the federal government do the heavy lifting of expanding coverage to roll up their sleeves and get to work by passing Medicaid expansion."
American Association of Neurological Surgeons: "While [the decision] settles the legal debate on the lawfulness of federal tax subsidies for individuals enrolled in federal health insurance exchanges, many problems with the Affordable Care Act remain. ... Despite the resolution of the insurance subsidy issue, Congress must take action to address the many broken promises of health reform."
Disclosures
Conway showed no relevant financial payments from industry.