Court Decisions Matter When it Comes to ACA Defense

By Alex Balletto |

Much of the recent Affordable Care Act drama we have been hearing about is in the courts.

With the election of a Democratic majority in the House of Representatives in the 2018 Election, the effort to repeal the ACA in Congress is dead, at least for now.  But that hasn’t stopped the Trump Administration from continuing to search out new ways to undermine the law.

ACA Court Victories

Pushback against this sabotage is now being fought out in the Federal courts.  Fortunately, since 2012, when the Supreme Court upheld Medicaid expansion and the individual mandate, the courts have mostly remained “pro”-ACA.

In 2015, the Court upheld the ACA’s premium tax credits to qualifying persons in all states. The Court’s decision held that whether the marketplace was established by the states or by the federal government, “Congress made the guaranteed issue and community rating requirements applicable in every State in the Nation.”

Recently several victories were handed down.

Cost Sharing Reduction payments

In February, two judges in the Court of Federal Claims ruled that insurers are entitled to receive unpaid cost sharing reduction (CSR) payments, after the Trump administration cut them off in 2017.  One case was a massive class action suit, involving 91 insurers.  There were similar decisions last year, too.  To-date, “every CSR case that has been decided so far has been won by insurers.”  To learn more about this case, go here.

Medicaid work requirements blocked

Following guidance issued by the Trump Administration, several states have initiated work requirements for Medicaid recipients.  In practice, these new rules set up complicated procedural hurdles that are difficult for those on Medicaid, including those who currently work, to meet.  Instead, they appear to be a thinly disguised mechanism to drop people from Medicaid coverage.

In late March, U.S. District Court Judge James Boasberg struck down Medicaid work requirements in Arkansas and Kentucky.  This ruling came almost a year after he blocked Kentucky’s first-proposed work requirements.  Essentially, he ruled that work requirements don’t align with Congress’ goal for the Medicaid program – that is to provide health coverage.  (More than 18,000 low-income adults lost coverage last year for not meeting requirements, according to Politico.)  Judge Boasberg is an appointee of President Obama.

It is hoped this loss in the courts will stop other states from implementing work requirements.  However, CMS Administrator Seema Verma said she will continue to accept work requirement waiver requests from other states.  Meanwhile, the Governor of Kentucky has threatened to undo the state’s Medicaid expansion if his efforts fail in court.

Association health plans blocked

The day after Medicaid work requirements were blocked, U.S. District Court Judge John Bates ruled against Association Health Plans (AHPs).  Not surprisingly, the Judge saw AHPs as “clearly an end run” around federal health law.

The administration’s AHP final rule allows small businesses to band together and offer insurance outside of the ACA.  Consequently, the plans don’t need to comply with the ACA’s essential health benefits (EHBs) requirements and are expected, therefore, to offer skimpy benefits.  By defying the requirement to cover EHBs, Judge Bates found that AHPs are clearly unlawful.  Judge Bates is an appointee of President George W. Bush.

Fortunately, Connecticut has not sought to implement Medicaid work requirements and requires that all health plans offered in the state cover essential health benefits.  But while these court victories are encouraging, there is one court case that is a cause for concern among supporters of the ACA, even here in Connecticut.

Texas v. Azar

In the same week that the courts delivered the wins on Medicaid work requirements and AHPs, the Trump Justice Department announced it would be filing a brief to support a court case, Texas v. Azar, that seeks to strike down the entire Affordable Care Act.  Normally, it is the job of the current administration to defend the law, even if it was passed under a previous administration with different political views.  So, this decision to file a brief in opposition to the ACA is highly unusual, and is apparently controversial even within the administration.

At first, the Trump Administration did not fully back striking the entire ACA, writing in a brief in June last year that the law’s other provisions are distinct from the mandate and can stand.  But on March 25, in a sudden reversal, the Administration announced it will support the District Court’s ruling altogether on appeal.

To read more about the Texas v. Azar case, go here or here.  You can also check out Kaiser Family Foundation’s brief, “Potential Impact of Texas v. U.S. Decision on Key Provisions of the Affordable Care Act”, here.

There are 21 states, including Connecticut that are appealing the ruling.