Tuesday, November 18, 2014

Time To Take Action To "Save Our Healthcare"

The Supreme Court is considering a case that could take away health insurance subsidies from working people in thirty-four States. Those are the States whose health insurance exchanges were set up by the Federal government, when those States refused to do so on their own. Seven states have actively sought to have the Supreme Court take away their citizen's health insurance and 27 others have sat on the sidelines, possibly in hope that the same thing happens to their citizens. We are talking about the health insurance of over 5 million people.

The people in those states have the capacity to influence the Court and at the same time bring to light the actions of their Governors, Attorneys General and Legislatures. That influence can be achieved by:

* Informing all those who have subsidized health insurance in each of the 34 states involved that their health insurance is at risk because those subsidies could be taken away by a decision of the Supreme Court.

* Informing these people that the governor and legislature in their state has either asked the Supreme Court to take away their ability to buy health insurance or has not asked the Court to protect their health care.

* Doing this could actually influence the governors and legislators in these 34 states to either retract their support for denying insurance subsidies or cause them to oppose a Supreme Court decision that would have that effect.

* Together, pressure from these states could have a real affect on the ultimate Supreme Court decision.

* At the very least, the hard working people of these states would understand who is on their side, who is looking out for their interests, and why they should hold their elected officials accountable.

The risk to the health insurance of these people began when the Supreme Court decided to hear King v Burwell. In that case a group of ACA opponents sought to undermine the law by arguing that a wording glitch in the law meant that people buying insurance on the Federal exchange could not get any subsidies. They lost the case in the District Court and the Appeals Court and are now seeking Supreme Court review.

In a sane world every state that did not set up an exchange would have supported the King v Burwell decision and would have said that there was no need for Supreme Court review. After all, these States did not have to spend money to set up an exchange. And if there are no subsidies available to their citizens through the Federal Exchange many of those folks will not be able to afford insurance. Also, unlike the issue of Medicaid expansion, this issue does not involve the expenditure of State funds. The States do not pay a cent towards these subsidies.

But it is not a sane world. There are 34 states which refused to set up health insurance exchanges and thus required the federal government to set up exchanges for them. Those exchanges are referred to by the Department of Health and Human Services as Federally Facilitated Exchanges. They cover 5,446,178 people. Of those over 5 million people, 86% receive subsidies enabling them to buy their insurance and the average subsidy is $4700. (This is May 1, 2014 data.)

Seven of those 34 states have actively sought to have the Supreme Court take away the insurance subsidies provided to their citizens. Those states are Oklahoma Alabama Georgia Indiana Nebraska South Carolina and West Virginia. Together, there are 2,573,585 people in those seven states who are receiving health insurance through the federally facilitated exchange for each of those states and 82% of those 2 1/2 million people are receiving subsidies. That means the governors, attorneys general, and/or legislature doors of those states are asking the Supreme Court to deny basic healthcare two over 2 1/2 million residents of those states.

But the sad truth is that many people in those states may be unaware of the actions of their elected officials. Is it conceivable that these people, many of whom have health insurance now for the first time, are aware that not only is their healthcare at risk but also that their elected officials are behind the effort to take it away? No, it is not, and for a simple reason. Most people simply have too much difficulty working their daily jobs, taking care of their families, and trying to keep their financial heads above water to spend time researching the intricacies of state government or health insurance policy, let alone the actions of the Supreme Court. It is not their fault that they may be unaware of what is about to happen to them but it would be our fault if we did not do everything possible to make them aware and give them the information needed to make their voices heard.

Now is theme for the people in these 34 states to become aware of what is being done or not being done in their names. They could start with letters to the editors from hard-working people whose health care is in jeopardy. They could also begin to circulate petitions to their governors, attorneys general, and state representatives. Social media could be used to spread the word and inform everyone of what is at stake.

The reality is the people who would be affected by a negative Supreme Court decision are hard-working people who seek only a modicum of health security for themselves and the members of their families. It is not too much to ask. Hopefully, their efforts could receive the attention of parties who have the financial resources necessary to begin an outreach campaign and even provide advertising in those states.

There is still plenty of time for people to take control of their future. But if they do not, they may find out too late that the health security they always wanted has been taken from them.

* * * * * *

It is not the purpose of this article to get into the merits of the challenge to the King v Burwell decision since that challenge ignores all precedent and all rules of statutory construction. However, for those who think that there is any serious merit to the argument that the Affordable Care Act does not authorize subsidies for state exchanges that are established within a federally facilitated exchange here are two things to consider.

The challengers sole argument is that one section of the law that refers to subsidies says that they are available on "an Exchange established by a State" and that these were established by the Federal Government not by States. The DOJ points out the same law imposes a mandatory requirement for each to set up an exchange, but provides that for any state that elects not to establish an exchange that Federal Government must establish one in its stead, and that for all purpose of the law each of those Federally Facilitated Exchanges is "an exchange established by a State." Here is the summary from the Solicitor General's brief, which eviscerates the challengers' arguments.

The Act provides that each State “shall * * * establish an American Health Benefits Exchange.” 42 U.S.C. 18031(b)(1). But, in a provision expressly designed to respect the sovereign dignity of each State by affording “State flexibility,” 42 U.S.C. 18041, the Act provides two ways for that requirement to be satisfied. First, a State may elect to create the Exchange on its own. 42 U.S.C. 18041(b). Alternatively, if a State does not elect to establish the “required Exchange” itself, then HHS will “establish and operate such Exchange within the State.” 42 U.S.C. 18041(c)(1). Either choice satisfies Section 18031(b)(1)’s requirement that each State “shall * * * establish an [Exchange].” The text of the Act thus makes clear that an Exchange established by HHS in a State’s stead is, as a matter of law, “an Ex- change established by the State.”

That interpretation harmonizes the Act’s text, structure, and purpose. Petitioners’ reading, in contrast, would transform the Act into a hash of superfluities, absurdities, and internal contradictions. It would obstruct the Act’s express purpose by denying affordable insurance to millions of Americans. It would thwart the operation of the Act’s interdepend- ent reforms and gut the Exchanges through which those reforms are implemented. And it would destroy the Act’s model of cooperative federalism by trans- forming the Act’s promise of “State flexibility” into a threat that a State may forgo establishing an Ex- change for itself only at the price of crippling its insurance market and depriving its citizens of the tax credits at the heart of the Act. The Act unambiguously forecloses that construction. At a minimum, the IRS’s interpretation is a permissible one meriting deference under Chevron.

The brief goes on to explain these arguments in detail. It is well worth the reading.

Next are the words of Justice Antonin Scalia in the case upholding the ACA, National Federation of Independent Business v Sibelius. He wrote a scathing dissent to the majority opinion upholding the constitutionality of the ACA and in the course of that dissent made clear his understanding that subsidies are available to all people purchasing insurance under the ACA, whether through a state established or federally facilitated state exchange. He makes no distinction between the two, as illustrated by this excerpt discussing the Medicaid portion of the bill. The discussion is a bit convoluted because he is saying that while there is a backup plan for the Federal government to set up an exchange for a state refusing to set up an exchange or cover legal aliens, including subsidies, there is no similar backup for a state refusing to expand Medicaid. And because there is no backup the Medicaid expansion is Unconstitutional. But what is important here is how he describes the statutory structure.

If Congress had thought that States might actually refuse to go along with the expansion of Medicaid, Congress would surely have devised a backup scheme so that the most vulnerable groups in our society, those previously eligible for Medicaid, would not be left out in the cold. But nowhere in the over 900-page Act is such a scheme to be found. By contrast, because Congress thought that some States might decline federal funding for the operation of a “health benefit exchange,” Congress provided a backup scheme; if a State declines to participate in the operation of an exchange, the Federal Government will step in and operate an exchange in that State. See 42 U. S. C. §18041(c)(1). Likewise, knowing that States would not necessarily provide affordable health insurance for aliens lawfully present in the United States because Medicaid does not require States to provide such coverage Congress extended the availability of the new federal insurance subsidies to all aliens. See 26 U. S. C. §36B(c)(1)(B)(ii) (excepting from the income limit individualswho are “not eligible for the medicaid program . . . by reason of [their] alien status”). Congress did not make these subsidies available for citizens with incomes below the poverty level because Congress obviously assumed that they would be covered by Medicaid. If Congress had contemplated that some of these citizens would be left without Medicaid coverage as a result of a State’s withdrawal or expulsion from the program, Congress surely would have made them eligible for the tax subsidies provided for.

Now, no one expects Justice Scalia to be consistent when it comes to the ACA. He has proven that his decisions are motivated purely by reactionary politics and have little to do with the law. However, it is very clear that he as well as all of the other justices who decided the original challenge to the ACA understood that subsidies were available to people buying insurance whether that insurance was purchased on an exchange established by a state or established for a state by the federal government. If they choose to do the mental gymnastics necessary to get around that simple fact, so be it. But everyone will know exactly what they are doing.

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