Supreme Court Decision

The Supreme Court upholds the ACA!
On Thursday, June 28th, 2012, the U.S. Supreme Court upheld the constitutionality of the Affordable Care Act, the landmark health reform law enacted in 2010. The American Public Health Association praises the Court’s decision. APHA’s executive director Georges C. Benjamin, MD, FACP, FACEP (E), said in a statement, “Today’s historic ruling by the nation’s highest court marks a significant milestone in our national efforts to improve the delivery and financing of health services in the U.S. and to promote health and wellness rather than disease treatment." The full press statement and press inquiry information are here.

This page contains information and resources to help you understand the decision and its implications. Background information and resources on the ACA cases and hearings and APHA's involvement has been stored here.

Key resources
(See full list of resources below) 

  • Recent webinar: Affordable Care Act implementation one year post-decision: Medicaid expansion, preventive services, and public health implications. Slides and recording from the June 26, 2013 webinar. Slides only (PDF).
  • In-depth analysis of the Court’s decision and its implications for Medicaid: prepared for APHA by the National Health Law Program and the Network for Public Health Law. Also read their initial analysis of the decision, prepared immediately after the ruling.
  • July 5th webinar on the ACA decision: The Supreme Court's Decision on the Affordable Care Act: Implications for Prevention and Public Health (slides and recording; slides only): co-hosted by APHA and other public health organizations, with panelists from the National Health Law Program, the Network for Public Health Law, and George Washington University.

Frequently asked questions 

Overview of the ruling

1. What did the Supreme Court say about the Affordable Care Act?

2. What does the Court’s ruling on the Medicaid expansion mean?

3. What does the Court’s ruling on the minimum coverage provision (individual mandate) mean?

4. What is the impact of the Court’s ruling on other aspects of the law?

5. Does the Court’s ruling have any impact on Congress’ attempts to repeal or defund ACA (in total or part)?

6. Could other legal challenges impact the ACA? 

Implications of the Court’s ruling on the Medicaid expansion

7. Which states have indicated that they will or won’t move forward with the expansion?

8. How many states are predicted to expand Medicaid?

9. What will happen to the individuals who would otherwise be eligible for Medicaid in states that choose not to expand Medicaid?

10. If a state chooses not to expand Medicaid, will the federal government do it instead?

11. What options will states have regarding timing and other details?

Frequently asked questions

Overview of the ruling

1. What did the Supreme Court say about the Affordable Care Act?
On June 28, 2012, the Supreme Court upheld nearly all of the Affordable Care Act. Importantly, both the minimum coverage provision (individual mandate) and the Medicaid expansion were upheld. However, the Court also said that the federal government can’t penalize states that don’t implement the Medicaid expansion. (This is explained further in the next question.) For more information, see the resources listed below. (FAQ top)

2. What does the Court’s ruling on the Medicaid expansion mean?  
The Supreme Court’s ruling means that the Medicaid expansion included as part of the ACA will move forward in all states that agree to participate. The only change is that the federal government may not threaten to withhold all Medicaid funding from a state that chooses not to participate in the expansion.

As the Affordable Care Act was written, states are required to expand Medicaid eligibility to all non-elderly legal residents with family incomes less than 133 percent of the federal poverty level (FPL) ($30,675 for a family of four in 2012), starting in 2014. Prior to the Supreme Court's ruling, if a state were to refuse to comply with this expansion in 2014, the Secretary of Health and Human Services (HHS) would have had the option to withhold all of the state’s Medicaid funding as a penalty. Now, instead of being able to withhold all of a state’s Medicaid funds if a state doesn’t comply with the expansion, HHS can only withhold new funds that would have been associated with the expansion. A state’s existing Medicaid funds cannot be withheld. Further questions and answers about the 
potential implications of the Medicaid expansion decision are found lower on this page. For more information, see the resources listed below. (FAQ top)

3. What does the Court’s ruling on the minimum coverage provision (individual mandate) mean?
The minimum coverage provision (individual mandate), which will require that most individuals in the U.S. obtain health coverage or pay a penalty, was upheld. The Court found that the penalty may be considered a tax, and therefore may be imposed under Congress’ taxing power. It is scheduled to take effect in January 2014.

The Court found that Congress did not have the power to enact the minimum coverage provision under the Commerce Clause of the Constitution, but that the taxing power alone is enough to uphold the provision. For more information, see the resources listed 
below. (FAQ top)

4. What is the impact of the Court’s ruling on other aspects of the law?
The Supreme Court’s ruling did not have any impact on the rest of the law. The entire ACA was upheld (with the exception of the limitation placed on the federal government’s ability to enforce the Medicaid expansion). Thus, the state-based exchanges, private insurance reforms, Prevention and Public Health Fund, and all other provisions, will move forward as planned. For more information, see the resources listed below. (FAQ top)

5. Does the Court’s ruling have any impact on Congress’ attempts to repeal or defund ACA (in total or part)?
The Supreme Court’s ruling is not directly related to Congress’ attempts to repeal or defund the ACA. In fact, the House voted to repeal the ACA soon after the Court’s ruling, and attacks on the Prevention and Public Health Fund in particular will likely also continue.  See APHA's letters to Congress opposing those attempts here. For more information, see the resources listed below. (FAQ top)

6. Could other legal challenges impact the ACA?
Yes. Other provisions of the ACA are being challenged in lower courts, including the contraceptive coverage requirement and federal subsidies to individuals for the purchase of coverage through exchanges. As stated by the Partnership for Public Health Law in an article prepared for the National Association of Local Boards of Health (NALBOH), “while [the current] lawsuits do not present as great a challenge as the ones already addressed by the Supreme Court, they could succeed in blocking implementation of parts of the law.” For more information, see the resources listed below. (FAQ top)

Implications of the Court’s ruling on the Medicaid expansion

7. Which states have indicated that they will or won’t move forward with the expansion? 
As of late July 2012, the governors of five states  have said they will block the ACA Medicaid expansion. Ten states plus the District of Columbia have already committed to implementing the expansion. More information about states’ intentions is expected after the November 2012 elections, and after HHS issues guidance interpreting the Court’s ruling on Medicaid. 

The Advisory Board Company, a health policy consulting firm, is maintaining this useful and interactive
tracker of states’ intentions regarding the Medicaid expansion. (Linked through State Refor(u)m.) For more information, see the resources listed below. (FAQ top)

8. How many states are predicted to expand Medicaid? 
While it's impossible to predict the future, many experts believe that even if it doesn’t happen right away, most (if not all) states will eventually participate in the expansion. At least three key issues are important to understand:

  • The ACA’s Medicaid expansion was written with both “carrot” and “stick” incentives. The “stick” is gone – the possibility of losing all Medicaid funding. However, the “carrot” remains – the fact that the federal government is initially financing 100 percent of the cost of the expansion, and will never finance less than 90 percent of it. This is a powerful positive incentive for states to implement the Medicaid expansion, as this federal contribution is much higher than the amount states receive to cover their other Medicaid populations.
  • The ACA also calls for a reduction in certain Medicare and Medicaid payments to hospitals, called disproportionate share (DSH) payments. These payments are meant to hospitals' costs of providing uncompensated care to those who are uninsured or underinsured. The ACA is reducing these payments based on the assumption that there will be fewer uninsured people, partially due to the Medicaid expansion. It's not clear what will happen to planned DSH payment reductions in states that don't expand Medicaid, but there is a possibility that in states that don't expand Medicaid, hospitals might face higher than anticipated numbers of uninsured patients, while still seeing cuts to their DSH payments. (Read more.)
  • When the CHIP (children's health insurance) program was expanded in 1997, and the federal government financed 70 percent of the costs, some states were resistant to the idea at first, but it took less than three years for all to commit to participating.
  • For more information, see the resources listed below. (FAQ top)

9. What will happen to the individuals who would otherwise be eligible for Medicaid in states that choose not to expand Medicaid?
People with incomes below 100 percent of the federal poverty level ($23,050 for a family of four in 2012) may have very few options if their state doesn't expand Medicaid. The ACA provides for income-based subsidies to help many individuals and families afford insurance in the new exchanges (insurance marketplaces), but in general, those exchange subsidies will only be available to people with incomes above 100 percent of the federal poverty line. If a state does not expand Medicaid, those with incomes below 100 percent FPL who do not meet their state’s current eligibility thresholds for Medicaid will not have any other options under ACA, unless the federal administration issues new guidance to that effect. For more information, see the resources listed below. (FAQ top)

10. If a state chooses not to expand Medicaid, will the federal government do it instead?
Until HHS issues regulations interpreting the Court’s decision, we won’t know certain details, but it’s not likely that the federal government will simply step in where states don’t expand Medicaid. However, under the ACA, if a state chooses not to create an exchange (a new marketplace where individuals and small businesses can compare and purchase private insurance), the federal government will create an exchange in that state.  
For more information, see the resources listed
below. (FAQ top)

11. What options will states have regarding timing and other details? 
Until HHS issues regulations interpreting the Court’s decision, we won’t officially know certain details, such as whether states can choose to partially expand coverage (ie, up to 100 percent of the federal poverty level instead of 133 percent), and whether they may opt in or out of the expansion at any time. However, health law experts at the National Health Law Project (NHeLP) and the Network for Public Health Law (NPHL) have prepared 
this analysis for APHA, in which they offer their understandings of potential implications. According to NHeLP’s and NPHL’s analysis,

  • "The Court’s decision does not authorize States to receive the higher federal match for implementing less than the full Medicaid expansion."
  • "Regardless of whether a State implements the expansion, the ACA’s other newly added Medicaid provisions continue in full force and effect, including requirements for coverage of young adults leaving the foster care system, Medicare-Medicaid rate parity for primary care providers and options for expanding coverage of community-based services and supports for people with disabilities and the elderly."
  • "Regardless of whether a State implements the Medicaid expansion, the ACA’s maintenance of effort (MOE) provision will continue to apply. This provision requires States to maintain their Medicaid eligibility as it stood on March 23, 2010, the date the ACA was enacted until “the State has an exchange approved by the Secretary.”
  • "Regardless of whether a State implements the Medicaid expansion, the modified adjusted gross income (MAGI) provisions for determining Medicaid eligibility will continue to apply. This new method for determining incomes for eligibility purposes, contained in  ACA § 2002, applies to most categories of non-disabled children and adults under 65 even without the Medicaid expansion."
  • "The enhanced federal matching provisions of the ACA are not affected by the decision. States that implement the Medicaid expansion will receive historically generous federal funding: 100 percent federal funding for services provided to newly eligible beneficiaries, to be phased to 90 percent over time. This compares with, on average, 57 percent federal funding for most Medicaid services."
  • "All States, regardless of whether they implement the Medicaid expansion, must still comply with all mandatory provisions of the Medicaid Act or risk losing all federal funding [as has always been the case]. Thus, for example, the requirement that Medicaid payments for services provided by Federally Qualified Health Centers (FQHCs) equal the reasonable average costs of furnishing those services remains in full effect."
  • For more information and citations, read the full analysis. For additional information, see the resources listed below. (FAQ top)

Additional resources
(includes key resources highlighted above.)

APHA resources

APHA statements, articles, and media mentions

Other resources on the Court's decision

Other resources on Medicaid expansion implications
(also see our Medicaid expansion page)

Other webinars

For more information, visit our Supreme Court Background, Medicaid Expansion, or our Useful Links pages.

APHA is continuing to update its health reform website and resources. Please check back as we add new content.   

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