ObamaCare Forever (maybe)…

Full Opinion and Dissent

The Supreme Court of the United States (SCOTUS) today handed down their decision in King v Burwell 576 US (2015), that they heard earlier this year. It was the last major challenge to the Affordable Care Act (or ‘ObamaCare’) coming through the court system, and the Justices voted 6-3 to uphold the Act as it was currently in force. And, the decision came down to what the definition of “state” is.

Obamacare didn’t create an US Version of the NHS, but it did make important changes to the American healthcare system. The Act provided that “each State shall…establish an American Health Benefit Exchange” [s.18031] but, they could opt-out of creating a State Exchange, in which case the Federal government “shall…establish and operate such Exchange within the State. [s.18041]”
These exchanges couldn’t turn people away based on pre-existing conditions, but in return everyone in America had to get insurance. This, appears unfairly harsh for the poorest, but the AFA had in it a compensatory mechanism. The poorest people buying Insurance from Government ‘Exchanges’ could get subsidies to help with the cost of healthcare.
It’s important to grasp just how intertwined these three things are – if you remove one strand (either the guaranteed acceptance, compulsory purchase and supported subsidy) then the whole system falls. If people can be knocked back, they can’t buy any healthcare. If people don’t have to have health coverage, they will only buy insurance when they need it, so they system becomes underfunded. And if you remove subsides for the worst-off, they can’t afford insurance, and so they are pushed into poverty to comply with the law.
It is this provision of subsidy which gave rise to the latest case

The AFA states that the subsidies are available to US Citizens who are enrolled in Health Insurance schemes through “an Exchange established by the State…” The question in this case was whether people who enrolled in their Health Insurance through an exchange run by the Federal Government (because the State didn’t create their own) were eligible for the subsidies too. It was, essentially, a question of statutory interpretation.

The SCOTUS Dissenters (Justices Scalia, Thomas and Alito) accepted the argument that the law was written the way it was deliberately, and that the clause must be examined literally. To quote the introduction of Scalia’s (rather forceful) dissent:

The Court holds that when the Patient Protection and Affordable Care Act says “Exchange established by the State” it means “Exchange established by the State or the Federal Government.” That is of course quite absurd, and the Court’s 21 pages of explanation make it no less so. [Page 1; Dissent]

This is exactly what was expected from Justice Scalia. Notwithstanding his being a conservative Justice on the court, he is an ardent adherent to literal interpretation of the Constitution and the law, seeking to look squarely at the words on the page. He gives a sucinct insight to his thought processes on page 2 of his dissent:

In order to receive any money under §36B, an individual must enroll in an insurance plan through an “Exchange established by the State.” The Secretary of Health and Human Services is not a State. So an Exchange established by the Secretary is not an Exchange established by the State—which means people who buy health insurance through such an Exchange get no money under §36B. [Page 2; Dissent]

This, it seems, is the clearest way to deal with the problem. If the law says something, we should give effect to that thing, even if they meant something else. Scalia spends 21 pages justifying this view.¹ Yet, despite these efforts, the majority of the court disagreed.

Instead, the majority argued that, in order to properly understand the law, you had to look beyond the immediate definition of the words. Justice Roberts, delivering the Opinion of the Court, made thrtwoee arguments that the phrase “established by the State” was at least ambiguous. The first was that, even if we were to take a literal approach to the Act, it was clear that there was not meant to be any difference between State-run and Federal-run exchanges. He suggests that when States don’t create an exchange, the Federal must “establish and operate such Exchange” (emphasis added). But saying “such exchange”, he argues that there is no difference between the two kinds of exchange – that Federal Government is merely doing the State’s function. [Page 10; Opinion]
Further, he examines the way the various sections of the Act interact with each other. The Act defines  “Exchange” to mean “an…Exchange established under section 18031″, which means that s.18041 (which establishes the Federal Government’s role in the whole affair), would actually mean that the Federal Government must “establish and operate such an Exchange established under section 18031”.
And, again, by using the words “such Exchange,” the Act indicates that State and Federal Exchanges should be the same. But, as I noted  at the outset, the tax credit subsidy is fundamental to the entire Act. So if tax credits were available only on state-run exchanges, it would go against the fundamental principles of the Act. [Page 12/13; Opinion] This is a far more purposive approach than Scalia’s dissent.
So why, then, did the Act include the phrase “established by the State” in s.18031 if it was so redundant? Why cause raise these questions in the first place? Roberts states that the Act “…contains more than a few examples of inartful drafting.” due the the way it passed through Congress. The Fact the Act was so contentious, required a great deal of compromise and had many, many redrafts led to an imperfect Act which was laden with small and unhelpful inconsistencies. [Page 14; Opinion]

So if the phrase “established by the State” is ambiguous, what should it be taken to mean? Should it have the smaller meaning to be literally “States”, or is there justification for a wider meaning? Roberts argues there is a justification – and it involves looking at the bigger picture. He accepts the argument that it is wrong to view the section in isolation, and it would be just as unhelpful to look at it simply within the context of the subsidising Tax credits, but instead, it must be examined within the entire Act. He states:

While the meaning of the phrase “an Exchange established by the State under [42 U. S. C. §18031]” may seem plain “when viewed in isolation,” such a reading turns out to be “untenable in light of [the statute] as a whole.” {Department of Revenue of Ore. v. ACF Industries, Inc., 510 U. S. 332, 343 (1994).} In this instance, the context and structure of the Act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase. [Page 20; Opinion]

A contextual approach is plain here, even moreso in the concluding statements in Roberts’ Opinion, where it is clear he had the aims of the Act at heart when seeking to decipher the ambiguous wording:

Th[e] credits are necessary for the Federal Exchanges to function like their State Exchange counterparts, and to avoid the type of calamitous result that Congress plainly meant to avoid.

and later:

Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter. Section 36B can fairly be read consistent with what we see as Congress’s plan, and that is the reading we adopt. The judgment of the United States Court of [both Page 21; Opinion]

Conclusion

Truth be told, I do harbour some sympathy for Justice Scalia’s literal approach. The phrase “established by the State” does seem to carry a clear and unambiguous meaning – but this only applies when it is looked at in that section alone. When viewed, not as a law of itself, but merely one provision in a series of many interlocking, interacting provisions which make up an Act, this clarity fades away. Further, when considering the legislative purpose of the Act which was passed (however imperfect and poorly drafted), it is clear there was intended to be no difference between State-run and Federal-run Health exchanges. Given the fundamental nature of the provision being debated, it would need require an explicit and clear instruction to create one, which the section in question certainly is not.

What will be interesting going forward  will be to see, now that the last Judicial challenge to the Affordable Care Act has been rejected, is whether those States who refused to open their own exchanges, will now do so. So close to an election, it is unlikely that the hard-line Republicans will change their position – but for the more moderate Congressmen and Governors, the growing acceptance (dare I say appeal?) of Obamacare, coupled with its growing permanency, may lead them to think again.


¹ You can read the entirety of Scalia’s dissent if you want, but here are some of my personal highlights:
 – The “most natural sense” of the phrase “Exchange established by the State” is an Exchange established by a State.
 – The Court’s next bit of interpretive jiggery-pokery involves…
 – We should start calling this law SCOTUScare.

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