1. Kaplan, Louise PhD, ARNP, FNP-BC, FAANP, FAAN

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In November 2020, the US Supreme Court heard a case challenging the Patient Protection and Affordable Care Act (ACA), the third Supreme Court case involving the law since its passage in 2010. In 2018, a federal judge ruled the ACA unconstitutional, which was followed by a ruling of the 5th Circuit Court that additional analysis by the federal court was needed. The Supreme Court agreed to review the case rather than have it return to the lower court.1


Eighteen states, led by Texas, along with the federal government, contended the 2017 Tax Cuts and Jobs Act that changed the shared responsibility payment for people who do not obtain health insurance (known as the individual mandate hereafter referred to as mandate) to $0, voided the ACA either in full or in part.1 Twenty-one states, led by California, were joined by the US House of Representatives to defend the law.1 This ruling has the potential to upend access to care and protections now available to millions of people.


Three core issues

The three issues argued before the court were about standing, constitutionality of the individual mandate, and whether the ACA can be severed if the mandate is unconstitutional. Standing refers to whether the plaintiff, in this case Texas and the other states, has been harmed by the law.2 Constitutionality refers to whether Congress can issue an individual mandate.2 Severability refers to whether part of a law that is determined to be unconstitutional can be eliminated without invalidating the entire law.2


The issue of standing was the focus of several of the Justices who seemed unpersuaded that the plaintiff had been harmed and had standing. Texas argued that increased Medicaid enrollment and higher administrative costs from the ACA reporting requirements was the basis of standing.3 California and the House of Representatives argued Texas and the other states that joined the suit did not demonstrate harm had occurred.4


Is the individual mandate constitutional? In 2012, the US Supreme Court upheld the mandate as constitutional in the case National Federation of Independent Businesses v. Sebelius on the basis of congressional authority to tax and spend.5 The plaintiffs in the 2020 case claimed that when Congress reduced the tax to $0 with the 2017 Tax Cuts and Jobs Act, it no longer qualified as a tax and rendered the mandate a command, which is unconstitutional. As a result, this would void the entire ACA.3 Justice Kagan commented during the Supreme Court hearing of the case that the elimination of a tax made the law less coercive and asked, "If you make a law less coercive, how does it become more of a command?"3


Linkage of the mandate and constitutionality relates to severability. If the individual mandate is eliminated as unconstitutional, can the rest of the law remain in effect, or does it need to be invalidated in its entirety? In this regard, Chief Justice Roberts commented during the hearing, "Congress left the rest of the law intact when it lowered the penalty to zero. This seems compelling evidence on the question."3


Implications of the Supreme Court ruling

There are several potential rulings the Supreme Court might issue. It could decide the plaintiffs have no standing to challenge the mandate; the mandate is constitutional, and the law stands; the mandate is unconstitutional and only that section is voided (meaning severed from the rest of the law); or the mandate is unconstitutional and cannot be severed from the law, rendering the law invalid.4


If the court decides the plaintiff does not have standing, there is no ruling on the law itself. If the mandate is considered constitutional, the law remains intact. Should the mandate be determined to be unconstitutional with only that section of the law invalidated, the ACA remains in effect as enforced currently.1


There is the possibility that the court could invalidate the mandate and other parts of the ACA, such as protection for preexisting conditions. The most significant effect would occur if the Supreme Court rules the ACA is unconstitutional and the law is overturned.1


There are approximately 18 million adult individuals currently with health insurance as a result of the ACA-either through the expansion of Medicaid or establishment of health exchanges from which people can purchase insurance. The consequences of invalidation of part or all of the ACA could be dire. Millions of individuals could lose health insurance coverage, and states would no longer receive Medicaid funding for people covered by the expansion. The attorney who argued the Supreme Court case for Texas appeared to recognize these interests and their significance if implemented immediately. Referring to a stay already in effect, which delays the effect of the lower court ruling, the Texas attorney commented, "If this Court were to agree with us that the ACA is invalid, that stay could be extended for an appropriate time to allow the states and political branches of the federal government an opportunity to accommodate those reliance interests...."3


A ruling that invalidates parts of the law, such as protection for people with preexisting conditions, coverage for adults under age 26 on their parents' insurance, and the Medicaid expansion, would also result in millions of people losing health insurance. An estimated 133 million people have preexisting conditions and could be denied health insurance coverage.6 States that expanded Medicaid coverage through the ACA increased Medicaid enrollment by 12.4 million between July 2013 and January 2020.7


The court will rule on California v. Texas in 2021 as late as the end of the session in June. This case has particular significance to NPs, with the country experiencing the profound and far-reaching effects of the coronavirus disease 2019 (COVID-19) pandemic. Millions of Americans have lost their jobs, often losing their health insurance as well, leading them to rely on the Medicaid expansion. Besides the millions who have contracted the virus and the hundreds of thousands who have died, many people have missed or skipped care for fear of being exposed to COVID-19 at a clinic or office. Practices have had to accommodate low clinic volumes often with staff furloughs and sometimes with closure.


Access to care for all people

If the ACA is invalidated, more people will become uninsured and will likely miss out on proper healthcare. While NP practice may be further destabilized in the coming months, an increase in the uninsured would result in additional poor health outcomes for those affected. Should the ACA be invalidated, it will be incumbent upon NPs to advocate for a law to replace it at both the state and federal levels. Should the ACA remain intact, it is incumbent upon NPs to be vigilant in support of the law and access to care for all people in need of healthcare. This is a responsibility of NPs who commit to healthcare as a right.




1. Musumeci MB. Explaining California v. Texas: a guide to the case challenging the ACA. Kaiser Family Foundation. 2020. [Context Link]


2. Wadill K. Supreme Court hears case on Affordable Care Act constitutionality. Heathpayer Intelligence. 2020. [Context Link]


3. US Supreme Court. California versus Texas, Case 19-840. Proceedings. 2020. [Context Link]


4. Keith K. Supreme Court arguments: even if mandate falls, rest of Affordable Care Act looks likely to be upheld. Health Affairs. 2020. [Context Link]


5. Jost T. The Supreme Court on the individual mandate's constitutionality: an overview. Health Affairs. 2012. [Context Link]


6. Office of the Assistant Secretary for Planning and Evaluation. Health insurance coverage for Americans with pre-existing conditions: the impact of the affordable care act. 2017. [Context Link]


7. Medicaid and CHIP Payment and Access Commission. Medicaid enrollment changes following the ACA. 2020. [Context Link]