APA Leaders Say Texas ACA Decision Is 'Unconscionable,' Call for Overturn

APA called for “a vigorous appeal effort” of last month’s decision by a Texas court that the entire Patient Protection and Affordable Care Act (ACA) is unconstitutional.

“This ruling has an unconscionable result,” said APA President Altha Stewart, M.D. “Should this ruling stand, millions of our patients will lose their health care. We cannot afford to go back to the days when Americans were denied coverage due to pre-existing conditions or when insurance companies would not cover mental health and substance use disorders.”

U.S. District Court Judge Reed O’Connor of Texas ruled that since Congress repealed the tax penalty associated with the individual mandate requiring people to have insurance, the mandate “can no longer be sustained as an exercise of Congress’ tax power” and is therefore unconstitutional. He further ruled that the individual mandate was essential to the ACA and could not be severed from its other components and that therefore the remaining provisions of the ACA are invalid.

“The Court today finds the Individual Mandate is no longer fairly readable as an exercise of Congress’s Tax Power and continues to be unsustainable under Congress’s Interstate Commerce Power,” O’Connor wrote. “The Court therefore finds the Individual Mandate, unmoored from a tax, is unconstitutional.”

He further wrote, “The Court finds the 2010 Congress expressed through plain text an unambiguous intent that the Individual Mandate not be severed from the ACA. [For that reason] the Court declares the remaining provisions of the ACA are inseverable and therefore invalid.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., echoed Stewart, saying the ruling must be overturned. “The court’s decision to invalidate the ACA, including pre-existing conditions protections and the Medicaid expansion, will hurt our patients with mental illness and all illnesses. This decision must be appealed and reversed.”

APA also joined five other major medical groups in a statement denouncing the ruling. “As frontline physicians who care for patients in rural, urban, wealthy, and low-income communities, we call for immediate appeal of the decision,” APA and the five groups said. “In addition, we urge the U.S. Congress and States to stand in strong support of protecting patient access to comprehensive health insurance coverage and join us in advocating for swift appeal. Finally, we urge the administration to continue implementing the law so our patients can continue receiving the care they need. Our message is simple: No one should lose the coverage they have.”

The five other organizations are the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Osteopathic Association.

Through private insurance reforms and Medicaid expansion, the ACA has provided coverage to roughly 2.8 million Americans with substance use disorders and 1.3 million Americans living with serious mental illness. An estimated 20 million Americans have coverage under the ACA.

O’Connor’s ruling was over a lawsuit filed this year by a group of Republican governors and state attorneys general. The ruling has no immediate effect, and multiple states immediately vowed to appeal the decision.

In a press statement three days after the ruling, the Department of Health and Human Services (HHS) said that for now there would be no changes to the ACA. “The recent U.S. District Court decision regarding the Affordable Care Act is not an injunction that halts the enforcement of the law and not a final judgment,” the department stated. “Therefore, HHS will continue administering and enforcing all aspects of the ACA as it had before the court issued its decision. This decision does not require that HHS make any changes to any of the ACA programs it administers or its enforcement of any portion of the ACA at this time. As always, the Trump administration stands ready to work with Congress on policy solutions that will deliver more insurance choices, better health care, and lower costs while continuing to protect individuals with pre-existing conditions.”

The New York Times reported that Xavier Becerra, the California attorney general, said California and the other defendant states would challenge the ruling with an appeal in the United States Court of Appeals for the Fifth Circuit in New Orleans.

On his Twitter account, Becerra said, “Every American could be impacted by this court decision: adults, whether they have employer-sponsored care or coverage through Medicaid, seniors benefitting from prescription drug discounts, and more. We’ll keep fighting it!”

Whatever happens in the court of appeals, the losing side will likely petition to the U.S. Supreme Court to hear the case.

If the Texas district court ruling is ultimately upheld, it would wreak havoc on the insurance market, and millions of Americans could lose the insurance coverage they have through the ACA’s expansion of Medicaid, the prohibition on discriminating against people with pre-existing conditions, and the provision allowing children under age 26 to be covered by their parents’ health plans.

In a statement in response to the Texas ruling, Frederick Isasi, executive director of Families USA, a health care advocacy group in Washington, D.C., said, “Families in our nation need to know—because the ruling does not take effect immediately and is being appealed—that their health care coverage and financial protections are not currently affected. So, they should continue to see their doctor when they need to.”

He added, “Invalidating the Affordable Care Act would devastate 20 million people with low-to-moderate incomes who would lose meaningful coverage, including 12 million people who get their coverage through the Medicaid expansion and 8 million who purchase coverage in the individual market using federal subsidies. It would overturn basic consumer protections that we all enjoy—such as the provision that allows children under 26 years old to be covered under their parents’ health plans, prohibiting insurance companies from imposing lifetime and yearly dollar limits on coverage, and mandating that they cover preventive care at no extra cost to consumers.”

Guidance Issued on ACA Waivers

In other news related to the ACA, the Centers for Medicare and Medicaid Services (CMS) issued four recommendations this past November outlining how states could restructure their health insurance markets, including shifting who would receive individual subsidy assistance under the ACA. The recommendations are aimed at lowering state barriers to innovation and increasing flexibility, according to CMS.

However, the new guidance allows states to apply for waivers to use subsidies for individual insurance policies that do not comply with the ACA, including short-term, limited-duration health plans and association health plans. Plans would not be required to provide the ACA’s “essential” health benefits, such as prescription drug, mental health, hospitalization, or maternity benefits. Such plans are less expensive than ACA-compliant plans, but they have been criticized by APA and other health care advocates for their skimpy coverage and lack of consumer protections (Psychiatric News, October 12, 2018 ).

The guidance would also allow states to provide less financial help to people with low incomes or high health care needs, according to a Kaiser Family Foundation analysis (KFF). In fact, states who obtain these waivers could shift federal subsidies to individuals not currently eligible for this federal assistance, including to higher income and younger people with fewer health care needs who opt to buy short-term plans that offer little coverage.

The CMS recommendations were issued as a discussion paper and involve Section 1332 of the ACA, which allows states to experiment with “waiving” certain provisions of the law. The paper elaborates on an administration guidance issued last October that substantially changed the standards for evaluating state waiver applications and replaced the Obama-era guidance on the topic. The guidance generally emphasizes private coverage over public coverage and encourages competition to contain spending growth.

Thus far, state waiver activity has been limited and mostly used by states to help them reduce the cost of ACA-compliant individual market policies, KFF wrote. ■