The stakes could not have been higher. Nothing less than the people's health and President Obama's legacy were at stake. At the end of a hard fought legal battle, the U.S. Supreme Court has upheld a key portion of President Barack Obama's healthcare law preserving health insurance for millions of Americans.
In a 6-3 decision, the Court said that tax subsidies that make health insurance affordable for low-income individuals can continue.
The ruling preserves the legislation, the Affordable Care Act (ACA) popularly known as Obamacare, which Mr. Obama considers a major part of his presidential legacy.
The case, King v Burwell, was the second major challenge the law has faced in the US's highest court. Unlike in many other western countries, the US does not have a single-payer healthcare system. Private companies, rather than the US government, provide health insurance for US citizens.
The decision sparked celebrations outside the court in Washington. Reading updates on their mobile phones, the crowd became jubilant when they learned mid-morning that the court had ruled in their favour. Some began dancing, while others chanted "If you're covered and you know it clap your hands."
The enactment of the Affordable Care Act (ACA) - one of Mr Obama's most significant and controversial domestic achievements - in 2010 mandated that every American had to purchase private insurance. It provided the subsidies to allow many to do so. The main focus of ObamaCare’s was on providing more Americans with access to affordable health insurance, improving the quality of health care and health insurance, regulating the health insurance industry, and reducing health care spending in the US.
In 2012, the U.S. Supreme Court ruled that the law, which requires that all Americans have health care, was constitutional.
In that decision, as in the decision on Thursday, Chief Justice John Roberts surprised observers by siding with his liberal colleagues in support of the law.
The ACA provides subsidies for those who can't afford to buy their own insurance but aren't poor enough to qualify for government care.States were encouraged to set up online marketplaces, or exchanges, so residents could shop around for the best price. But lots of states who opposed the law didn't do that, so there's also a federal exchange, healthcare.gov. Citizens in states that refused to establish exchanges could shop for coverage on this federal exchange.
The text of the law states that subsidies are available for anyone who gets care via exchanges "established by the State."
The dispute between the parties centred on whether the law permits tax credits for individuals who enroll in an insurance plan through a Federal Exchange
In the court the petitioners argued that the phrase "established by the state," meant the federal government could only provide subsidies to people in states that set up their own exchanges.
However, most Americans receiving subsidies purchase healthcare through the federal exchange, after many states decided not to set up their own marketplaces. Only 13 states and Washington DC have set up their own exchanges.
The Obama administration argued that was a too-narrow reading of the law, which spans nearly 1,000 pages, and the rest of the legislation makes clear subsidies are intended for those who meet income requirements, regardless of which exchange insurance was purchased from.
In a 6-3 decision, the court ruled for the Obama administration, saying the law as a whole allowed subsidies to everyone, despite "inartful drafting" of the bill. If the court had ruled the other way, 6.4 million people on the federal exchange who couldn't afford their care would have stopped receiving subsidies to pay their monthly bills. Without that subsidy - the average is more than $270 a month - most of those people had been expected to drop their insurance coverage.
"Congress passed the Affordable Care act to improve health insurance markets, not to destroy them," Chief Justice John Roberts wrote in the opinion upholding the contentions of the Obama administration.
Justice Anthony Kennedy who had dissented earlier in 2012, sided with the majority on Thursday.
Had the court made the opposite decision, an estimated 8.7 million people in the US would have been at risk of losing the aid that makes healthcare affordable.
Holding that the phrase “an Exchange established by the State under [Section 18031]” is unambiguous, the Court said it “must turn to the broader structure of the Act to determine the meaning of Section 36B.”
The Court said : “Congress based the Affordable Care Act on three major reforms: first, the guaranteed issue and community rating requirements; second, a requirement that individuals maintain health insurance coverage or make a payment to the IRS; and third, the tax credits for individuals with household incomes between 100 percent and 400 percent of the federal poverty line. In a State that establishes its own Exchange, these three reforms work together to expand insurance coverage. The guaranteed issue and community rating requirements ensure that anyone can buy insurance; the coverage requirement creates an incentive for people to do so before they get sick; and the tax credits—it is hoped—make insurance more affordable. Together, those reforms “minimize . . . adverse selection and broaden the health insurance risk pool to include healthy individuals, which will lower health insurance premiums.” 42 U. S. C. §18091(2)(I).
The Court said under petitioners’ reading the Act would operate quite differently in a State with a Federal Exchange. “As they see it, one of the Act’s three major reforms—the tax credits—would not apply. And a second major reform—the coverage requirement—would not apply in a meaningful way. As explained earlier, the coverage requirement applies only when the cost of buying health insurance (minus the amount of the tax credits) is less than eight percent of an individual’s income. 26 U. S. C. §§5000A(e)(1)(A), (e)(1)(B)(ii). So without the tax credits, the coverage requirement would apply to fewer individuals.”
However rejecting the petitioners’ reading of the provisions, the Court said : “The combination of no tax credits and an ineffective coverage requirement could well push a State’s individual insurance market into a death spiral… It is implausible that Congress meant the Act to operate in this manner.”
The Court also added that the structure of Section 36B itself suggested that tax credits are not limited to State Exchanges.
Summing up their opinion, the majority said : “In a democracy, the power to make the law rests with those chosen by the people. Our role is more confined—“to say what the law is.” Marbury v. Madison, 1 Cranch 137, 177 (1803). That is easier in some cases than in others. But in every case we must respect the role of the Legislature, and take care not to undo what it has done. A fair reading of legislation demands a fair understanding of the legislative plan.
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.”
Justice Antonin Scalia, who was among the 3 judges who dissented with the majority ruling, said Chief Justice Roberts’ decision made a mockery of legal reasoning.
Justice Scalia said his colleague engaged in “interpretive jiggery-pokery” and “somersaults of statutory interpretation” to find a way to defend the law.
Justice Antonin Scalia wrote in his dissent that the Supreme Court is setting a precedent of favouring some laws over others.
"We should start calling this law Scotuscare" Justice Scalia wrote, referring to the court's acronym. "Today's interpretation is not merely unnatural; it is unheard of. Who would ever have dreamt
that “Exchange established by the State” means “Exchange established by the State
or the Federal Government”? Little short of an express statutory definition could justify adopting this singular reading…. the only pertinent definition here provides that “State” means “each of the 50 States and the District of Columbia.” 42 U. S. C. §18024(d). Because the Secretary is neither one of the 50 States nor the District of Columbia, that definition positively contradicts the eccentric theory that an Exchange established by the Secretary has been established by the State.”
Justice Scalia was joined in his dissent by Justices Clarence Thomas and Samuel A. Alito Jr. “The cases will publish forever the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takes to uphold and assist its favorite.”
The ruling reverberated immediately on Capitol Hill, but legal analysts said it has implications far beyond the Affordable Care Act because it opens an avenue for judges to substitute their own judgments for the intentions of Congress.
The upholding of the law cements President Obama's biggest legislative victory. Limiting the subsidies could have unravelled Mr Obama's signature healthcare reforms.
Read the Judgment here.