As trusted sources of information related to health and health care, nurses should be informed about health care laws that govern access to care.

The issue.

On June 17, 2021, the Supreme Court of the United States (SCOTUS) rejected the latest constitutional challenge to the Affordable Care Act (ACA). The ACA lawsuit was linked to the Tax Cuts and Jobs Act of late 2017, which “zeroed out” the penalties imposed by the ACA’s controversial individual mandate requiring people to have health insurance. Following this, in February 2018 a coalition of 18 states and two individuals filed a lawsuit challenging the legality of the ACA because the individual mandate was unenforceable.

While most pundits initially dismissed the seriousness of the threat of the lawsuit, this changed in June 2018 when the U.S. Department of Justice under President Trump expressed support for the suit, asking the court to strike down not the entire law but just the ACA’s prohibitions against insurers’ denying coverage to people with preexisting conditions and against charging higher premiums because of health status (the Justice Department later expanded its support of the lawsuit to include repeal of the entire ACA). Historically, it is unusual for the Justice Department to oppose current law.

Rationale for the SCOTUS ruling.

Supreme Court justices rejected the claims of the plaintiffs because they deemed that the plaintiffs lacked standing (the right to initiate the lawsuit). To establish standing, the plaintiff must show personal injury has occurred or will occur, is attributable to the defendant’s alleged unlawful conduct, and is likely to be redressed by the relief sought. Standing in this case related to whether Texas and the other states had the right to sue; SCOTUS ruled that they did not and went no further.

Three strikes and you’re out?

This case was the third failed legal challenge to the ACA at the Supreme Court level. Let’s look at the trends. The most recent 7-2 ruling is the highest margin yet. The votes were 5-4 for the first case and 6-3 for the second case. Many pundits interpret this trend as a message that SCOTUS is less and less interested in revisiting the law in the courts and a possible indication of the final defeat of efforts to repeal the ACA. I agree that these trends appear significant.

What was at stake if the ACA was overturned?

As nurses who see the results when sick people don’t seek care early and routine preventive care is overlooked, it’s important to realize that striking down the ACA would have increased the numbers of uninsured Americans by 21 million, according to an estimate by the Urban Institute. In addition to the loss of multiple consumer protections, including the popular protection for those with preexisting health conditions, the biggest loss of coverage would have been among low-income adults who gained Medicaid coverage when the law expanded eligibility requirements to include them. In addition, millions of Americans would have lost private insurance, including families whose income met the threshold to qualify for subsidies to pay monthly insurance premiums.

Implications for the ACA going forward.

In the wake of years of unsuccessful challenges to the ACA, and despite the steady erosion of various ACA provisions and outreach by other means under the Trump administration, the law is far more stable than in the early years and accepted by more Americans than previously.

But improving on the ACA will not be easy in today’s political environment. Are current efforts enough to fill America’s remaining coverage gaps and keep the system viable? The public option plan President Biden touted during the campaign is barely mentioned these days, and the perennial problem of lowering health care costs, both that of patient care and of skyrocketing drugs costs, remains difficult to address without bipartisan support, given the strength of likely opposition from powerful health care industry players.

Efforts to strengthen the ACA.

That said, the current administration has already taken steps to strengthen the ACA, including expanding marketing, outreach, and assistance that had been slashed under the previous administration and reversing individual states’ approvals of Medicaid work requirements that would have stripped coverage from many people only recently added to Medicaid rolls.

In addition, President Biden signed the American Rescue Plan Act into law in March. Several provisions of this multipart act are intended to address the long-term criticism that premiums of many ACA marketplace plans have been unaffordable for many Americans. The American Rescue Act, which will be in effect only through 2022, grants premium subsidies to purchase insurance to millions with incomes that did not previously qualify.

Like any relatively new program as comprehensive as the ACA, incremental improvements are needed. Nurses can be instrumental in pushing for reforms to reduce disparities and promote equity. Nurses need to be informed and engaged in the policy making process to improve health care.

Carole Myers, PhD, RN, FAAN, professor at the University of Tennessee College of Nursing