MHAPA is excited that the Supreme Court has largely upheld the Affordable Care Act. We can now move on with the business of implementation and expanding access to mental health and substance use treatment and prevention and promotion to millions of Americans. Here are a few updates/resources to help understand the ruling.
Resources on the decision:
Mental Health America press release
Individual Mandate. The individual mandate was upheld based on the Administration’s third argument that the feds may impose a tax, not that the mandate is constitutional. Here’s a quote from p. 44, footnote 11 of the opinion – “Those subject to the individual mandate may lawfully forgo health insurance and pay higher taxes, or buy health insurance and pay lower taxes. The only thing that they may not lawfully do is not buy health insurance and not pay the resulting tax.”
In upholding the mandate, they also upheld the other provisions of the ACA that hinge on it – the guarantee issue of benefits despite preexisting conditions and the establishment of the insurance Exchanges.
Individual mandate vote – Justice Roberts upheld the mandate by voting that the tax on individuals was constitutional and was joined by the 4 other justices (Ginsburg, Sotomayor, Kagan, Breyer) who also voted that the mandate itself was constitutional. Kennedy, Scalia, Alito and Thomas voted the mandate unconstitutional.
Individual mandate on SCOTUS blog.
Medicaid Expansion. The Court ruled to narrowly limit the Medicaid expansion benefit. Specifically, the Court ruled the federal government can offer funds to states to expand Medicaid and if states opt to expand and take those funds, they must comply with the requirements of the program. The Court also ruled that states can opt out of the Medicaid expansion and if they do, it won’t affect their reimbursement for traditional Medicaid. In other words, current Medicaid programs for those who are categorically eligible would maintain the federal match even if states refuse to comply with the Medicaid expansion.
Medicaid vote. The vote was a bit complicated because there were several opinions within this vote. Bottom line – 7 Justices (Roberts, Breyer, Kagan, Scalia, Kennedy, Thomas, and Alito) found the expansion unconstitutional, but 5 justices (Robers, Ginsburg, Breyer, Sotomayor and Kagan) found that only the provision allowing the federal government to withhold all Medicaid dollars for non-compliance with the expansion program should be struck down. To break it down – Roberts, Kagan and Breyer voted that if states refuse the Medicaid expansion their other federal funding could not be compromised. Ginsburg and Sotomayor held that the entire expansion program is constitutional, even with the provision that states would lose all federal Medicaid funding for non-compliance. Scalia, Kennedy, Thomas and Alito agreed that withholding all federal Medicaid dollars for non-compliance with the program was unconstitutional, but held that therefore the entire expansion program should be invalidated, so even states who chose to participate could not. In the end, Ginsburg and Sotomayor voted that if the statute was unconstitutional because it coerced states into the Medicaid expansion by denying other Medicaid funds, then they would maintain the program and eliminate the provision disallowing states to get any Medicaid funding unless they opted for the Medicaid expansion (joining Roberts, Kagan and Breyer).
Medicaid expansion on SCOTUS blog.