In a 6-3 decision, the Supreme Court ruled today that federal subsidies being provided to individuals insured under the Affordable Care Act (ACA or Obamacare) in 36 states that do not have state run exchanges are lawful under the constitution.
Chief Justice John G. Roberts Jr., writing for the majority, stated: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”
It is estimated that 85% of those who use the exchanges for health care qualify for income-based subsidies. The argument to remove these subsidies was based on original language for the Affordable Care Act that stated such subsidies would be available for state run exchanges. Since 36 states did not choose to set up their own exchanges, it was argued that the federal exchange should not be able to provide subsidies to individuals in these states.
This would have left an estimated 7.5 million individuals without subsidies to help pay for their health care.
Why do I care?
1. When 7.5 million individuals don’t have access to regular medical exams, screenings, medications, and treatment options, we have a public health nightmare on our hands. Health disparities continue to worsen among those who do not have access to care. We are more vulnerable when the threat of infectious disease looms.
2. An article I co-wrote in 2004 for the Journal of Health Communication explains that reducing the use of the emergency room as a first option for care represents tremendous cost savings for the health care system. When people don’t have a medical home, they are more likely to resort to the emergency room for their care.
3. Had this ruling struck down the subsidies, the entire Affordable Care Act would have been vulnerable. This was attempt to cut the act down at the knees. I care about this on a personal level for several reasons.
- As a self-employed individual, I was able to purchase health insurance through Covered California (the California-run exchange) for nearly $150 less per month than the quote I received through COBRA to keep my former employer-sponsored plan.
- As an individual with a pre-existing condition, I would not have been assured health care as a self-employed individual prior to the ACA. The fact that the ACA prohibits companies from rejecting individuals based on pre-existing conditions gave me the security I needed.
Prior to the ACA, there were horror stories of children and adults alike who could not get the health care they so desperately needed, because they were sick. Michael Moore explored this in “Sicko”, where one of the stories he follows states that an individual did not qualify for cancer treatment because her cancer was a pre-existing condition. Sadly, we are still fighting this battle as many with chronic health conditions are struggling to have their medications or specialty care covered. We would have been further crippled in this fight if access had also put on the chopping block.
In closing, I care about this issue because of the years that I have spent studying health care policy. When I was working on my doctorate, I learned from professors who were working with President Obama to create the Affordable Care Act. When I taught Health Disparities this past Winter at UCLA, I told my undergraduate students that policy is a major driver and predictor of our population’s health.
How Policy Drives Health
Under, Lyndon B. Johnson’s Great Society, legislation passed between 1964 and 1966 to establish Medicare, Medicaid, and programs like Head Start provided access to insurance, education, voting rights, and employment. Infant mortality dropped among the poor, and gaps in minority health narrowed–some of which later reversed under subsequent policies. An eye-opening article in the International Journal of Epidemiology, looking for unique factors to explain why the US has a higher infant mortality rate than both developed and less developed countries–found a relationship between infant mortality rates and the political party in office.
Towards the end of last quarter, the students were introduced to the Supreme Court case challenging federal subsidies under the ACA. They found it shocking that a case brought on the behalf of four individuals could have implications for 7.5 million individuals. The case rested on the argument that these four individuals did not want health insurance, and were required to have it because with the help of the subsidies, they could afford it. If the subsidies were taken away, they would not be subject to the mandate.
It is my hope that understanding the implications of policy helped my undergraduates–future doctors and policymakers–ask deeper questions. I hope that the decision that was made today will help you ask deeper questions as well.
What type of society do you want to create? What legacy do you want to shape for future generations?
Portia Jackson is an independent public health consultant and a speaker and coach focusing on burnout prevention among millennials.
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