SCOTUS Dismisses Threat to Obamacare Once More

The U.S. Supreme Court batted down a lawsuit led by several Republican states and the former Trump administration that challenged the constitutionality of the Affordable Care Act (ACA), upholding the law for a third time.

In a vote of 7-2 on Thursday, the justices ruled that challengers lacked legal standing to bring forward the case. The decision to toss the suit preserves the landmark healthcare law and access to health plans for millions of Americans.

The case centered around the constitutionality of keeping the ACA in place after the penalty for the individual mandate -- a requirement that Americans enroll in a health insurance plan -- had been zeroed out.

But justices appeared sympathetic to keeping the law intact during oral arguments last November, and on Thursday, they argued that the plaintiffs had not been injured by the provision in question.

"Plaintiffs in this suit failed to show a concrete, particularized injury fairly traceable to the defendants' conduct in enforcing the specific statutory provision they attack as unconstitutional," concluded Justice Stephen Breyer, who penned the majority's decision. "They have failed to show that they have standing to attack as unconstitutional the Act's minimum essential coverage provision."

Moreover, Breyer noted, legal standing "requires identification of a remedy that will redress the individual plaintiffs' injuries ... No such remedy exists here."

Therefore the case was dismissed.

In 2012, Chief Justice John Roberts joined the four liberal justices on the court at the time, NFIB v. Sebelius, for a 5-4 decision that upheld the constitutionality of the individual mandate by deeming it a tax.

In 2015, the healthcare law faced another challenge, this time over whether Americans who bought health insurance through the ACA's exchanges had a right to receive subsidies to help them afford their premiums. In that instance, the Supreme Court ruled 6-3 to maintain subsidies for those receiving them through the exchanges. The late Justice Antonin Scalia as well as Justices Clarence Thomas and Samuel Alito dissented.

On Thursday, Justices Brett Kavanaugh and Amy Coney Barrett -- both appointed by former President Trump -- joined the Chief Justice, as well as Justices Sonia Sotomayor, Elena Kagan, Thomas, and Breyer, in upholding the ACA. Justices Neil Gorsuch, also appointed by Trump, and Alito dissented.

The high court "resoundingly rejected" the challenge and therefore "the ACA remains the law of the land," said Katie Keith, JD, MPH, a research professor at Georgetown University's Center on Health Insurance Reforms who teaches courses on the ACA and LGBT health law and policy at Georgetown University Law Center, in summarizing Thursday's decision.

"They didn't think the lawsuit was strong enough to be in court in the first place because none of the plaintiffs -- neither the individuals nor the states -- are actually harmed by a penalty-less mandate," Keith wrote in an email to MedPage Today.

Timothy Jost, JD, emeritus professor of law at Washington and Lee University in Lexington, Virginia, agreed.

In broad strokes, he explained the three questions at issue in the suit: First, did the plaintiffs have standing? In other words, did the provisions they singled out harm them in a way that the court could fix? Second, was the penalty-less individual mandate unconstitutional? And third, if the bar for both standing and unconstitutionality had been met, just how much of the rest of the law should be abolished?

"They slammed the ... first door and therefore never got to the second or third questions," Jost said.

While, in theory, the decision creates an opening for a plaintiff who can show standing, Jost sees that as very unlikely.

"I think that it's becoming clearer and clearer that ... if anybody's going to change the Affordable Care Act, it's going to have to be Congress and not the Supreme Court," he said, highlighting the widening gap in vote tallies: first a 5-4 decision, then 6-3, and now 7-2.

Leaders at the Heritage Foundation, a conservative think tank, drew a similar conclusion.

"Today's ruling reminds us that Congress needs to return to health reform," Kay C. James, the foundation's president, said in a press release.

"Many Americans still need relief from the rising healthcare costs and shrinking coverage options that have resulted from the Affordable Care Act," she said, arguing that conditions in the individual market have "worsened dramatically" following the passage of Obamacare.

She called on lawmakers to pass "The Health Care Choices Proposal," which would "protect Americans and improve their health care options without settling for the failures that are part of Obamacare's flawed design."

Advocates of the landmark healthcare law, however, were delighted and relieved.

"Eliminating the coverage, benefits and protections provided by this law would have thrown our health care system into chaos, and placed health care for millions of Americans in jeopardy. We are glad that the justices saw the need for the law to remain in place," said George M. Abraham, MD, MPH, president of the American College of Physicians, in a press release.

Abraham noted that a million more Americans took advantage of the special enrollment period this spring, thanks to "additional cost savings" included in the American Rescue Plan.

"Our hope is that now that the ACA is firmly settled law, that we can continue to find ways to improve it and to improve our health care system."

In a press release from health advocacy non-profit Families USA, Frederick Isasi, the organization's executive director, stated that "Hundreds of millions of people with preexisting conditions can sleep soundly tonight, knowing their health care protections won't be ripped away."

Noting the current Supreme Court's even more conservative makeup than during past challenges, Isasi added that the court's "strong opinion will almost certainly foreclose other craven, ideological lawsuits."

"The war on the ACA may finally be over," he said.

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