The Affordable Care Act, better known as Obamacare, has survived its third Supreme Court challenge. On Thursday, America’s highest court ruled in California v. Texas that allowed the entirety of the law as it currently exists to stay. It capped a decade-long attempt from the Republican Party to kill the largest overhaul to the U.S. health care system since Medicare and Medicaid in 1965.
This third attempt to repeal the ACA began years ago. In 2012, the Supreme Court had ruled that, in a shocking decision that saw Chief Justice John Roberts join the court’s four liberal justices, the ACA’s health insurance individual mandate was constitutional as it was a form of taxation. The individual mandate was a provision in the ACA that required all individuals to purchase health insurance or be fined. In that case, National Federation of Independent Business v. Sebelius, upheld this fine under Congress’s taxation power given in the Constitution.
However, in 2017, after Republicans were able to retain control of both houses of Congress and seize the presidency in the 2016 election, the Republicans tried to get rid of the mandate by simply reducing the penalty down to zero in Trump’s Tax Cuts and Jobs Act, which began in 2019. The bill was signed after the Republicans tried, but failed, to ram through a bill that would repeal most of the ACA’s provisions. That bill, known as the American Health Care Act of 2017, passed the Republican-controlled House but failed to clear the Republican-controlled Senate after three Republicans, including Sen. John McCain of Arizona, voted against the bill.
After the individual mandate was effectively removed, in February 2018, Texas, along with 19 other states, filed a lawsuit in the U.S. District Court for the Northern District of Texas challenging the constitutionality of the ACA after the individual mandate was removed. In that suit, originally known as Texas v. Azar, the plaintiffs argued that because the individual mandate was removed, and was seen as a core provision of the act as decided in Sebelius, the entire law should be an unconstitutional use of Congress’s taxation power.
In December 2018, the presiding judge agreed with the plaintiffs and struck down the entirety of the ACA as unconstitutional. However, the judge granted a stay on his ruling until the case could be appealed.
Under the helm of the Trump administration, which had campaigned on removing the ACA, the Department of Justice refused to appeal the case. Therefore, California, along with 17 other states, filed an appeal in the U.S. Court of Appeals for the Fifth Circuit over the district court’s decision in January 2019.
In late 2019, the Fifth Circuit announced that it believed that some provisions of the ACA were unconstitutional, but it could not decide which provisions were such, and sent it back down to the district court. Due to the fact that the court could not decide which aspects of the ACA were unconstitutional, it remained in force.
The group of states led by California brought the case to the Supreme Court in January 2020 petitioning for the court to hear the case and overturn the lower court’s ruling. The group led by Texas also petitioned the court to hear the case, but to uphold the lower court’s ruling. Ultimately, the California coalition consisted of 21 states plus the District of Columbia, while the Texas coalition consisted of 18 states.
The court agreed to hear the case, consolidated as California v. Texas, in March 2020 and oral arguments were heard on November 10, 2020, just a week after the 2020 presidential election. After the Biden administration took office this January, it submitted a brief to the court stating that the DOJ’s position on the ruling had changed and it was now against overturning the ACA.
The court decided the case in a 7-2 decision, penned by Justice Stephen Breyer and joined by Justices Amy Coney Barrett, Elena Kagan, Brett Kavanaugh, Sonia Sotomayor, and Clarence Thomas. It stated that the Texas coalition lacked standing to bring the challenge against the act after the individual mandate was struck down since it could not show a past or future injury related to the mandate, though it did not address whether the mandate was constitutional.
In the majority opinion, Breyer wrote that the plaintiffs have “not identified any unlawful action that has injured them” and stated that the plaintiffs “failed to show that the challenged minimum essential coverage provision, without any prospect of penalty, will harm them by leading more individuals to enroll in these programs.”
The dissent was penned by Justice Samuel Alito and joined by Justice Neil Gorsuch. It called out the decision as “the third installment in our epic Affordable Care Act trilogy” and “in all three episodes, with the Affordable Care Act facing a serious threat, the Court has pulled off an improbable rescue.”
“No one can fail to be impressed by the lengths to which this Court has been willing to go to defend the ACA against all threats. A penalty is a tax. The United States is a State. And 18 States who bear costly burdens under the ACA cannot even get a foot in the door to raise a constitutional challenge,” Alito wrote.
The decision was a major victory for health care activists. Had the law been struck down, over 30 million people could have been denied health insurance coverage, as the ACA mandates insurers to insure people with preexisting conditions without extra charges. At least 21 million people would have become uninsured without the ACA, according to the Urban Institute.
President Joe Biden applauded the bill, describing it as a “BFD” (big f***ing deal) on Twitter. Secretary of Health and Human Services Xavier Becerra said, “Today’s decision means that all Americans continue to have a right to affordable care, free of discrimination.” Becerra, who previously served as California’s attorney general, helped defend the law in the Supreme Court.
The case was also the widest margin by which the court upheld the act — the first time, five justices (four liberal, one conservative) upheld the law, in the second, six justices (four liberal, two conservative) upheld it, and now, seven justices (three liberal, four conservative) upheld it.
It now opens the doors to the Democrats, who control the government, to expand the act by further expanding health insurance subsidies, expanding Medicare by lowering the eligibility age, or even providing a government-run “public option” health insurance plan.
This ruling likely spells an end to the decade-long Republican attempt at trying to overturn the law. With majorities of Americans supporting the law and having gone through many unsuccessful attempts at repealing it, the ACA is likely to remain in the future.
Hardly any Republicans commented on the law, a stark contrast to 2012 when every leading Republican politician opposed it. It seems that the battle over health care is about to take a new shape.