U.S. Supreme Court upholds landmark health reform law
=====================================================

* Charlotte Tucker

After more than two years of questions about whether it would hold up in court, the Patient Protection and Affordable Care Act stands. The June Supreme Court decision means that more than 31 million previously uninsured people will be able to obtain health coverage by 2019.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/42/6/17.1/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/42/6/17.1/F1)

Angela Botticella, center, of Know Your Care, Know Your Support, celebrates with supporters of the Affordable Care Act outside of the Supreme Court in Washington, D.C., as the decision was announced on June 28.

Photo by Chris Maddaloni, courtesy Roll Call/Getty Images

Looking beyond the politics and the polemics, the Supreme Court’s decision means that public health will have within its arsenal a vast range of tools to fight the health problems that plague the United States.

In the June 28 ruling, the court found the Affordable Care Act and the requirement to obtain insurance or pay a small penalty constitutional. But it also said that states cannot be financially penalized for not expanding their Medicaid programs to cover more people.

APHA Executive Director Georges Benjamin, MD, FACP, FACEP (E), said the decision “marks tremendous progress toward reshaping our health system into one that saves the lives of at least 44,000 people who die annually simply because they do not have health insurance that could keep them healthy.”

“The Supreme Court did the right thing by upholding the Affordable Care Act,” Benjamin said. “APHA is overjoyed by today’s ruling.”

Unfortunately, just because the Supreme Court ruled on the Affordable Care Act does not mean the fight is over. Since its passage in March 2010, Congress has held votes to repeal the law more than two dozen times, and some opponents have pledged to continue the attacks. In fact, just two weeks after the court’s decision, some House lawmakers made another attempt to repeal the law.

In the meantime, health reform moves ahead. Though big parts of the Affordable Care Act, such as state-based health insurance exchanges, do not go into effect until 2014, the law phased in other reforms that have already made an impact. Starting in the 2011 fiscal year, community health centers saw increased funding that allowed them to nearly double the number of patients they were seeing.

Beginning in 2010, young people were permitted to remain on their parents’ insurance until they turned 26. That change meant that 3.1 million young people had health insurance who were not able to obtain it through school or employers before. The law also helped children with pre-existing conditions get coverage, and 14 million children with private insurance received preventive health services with no co-pay, according to the American Academy of Pediatrics.

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/42/6/17.1/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/42/6/17.1/F2)

A woman shows her support for the Affordable Care Act decision outside the Supreme Court on June 28.

Photo by Andrew Harrer, Bloomberg/Getty Images

The law also gives 54 million families better access to preventive health care services, such as vaccines and preventive care and screenings for women.

Among the tools created by the Affordable Care Act is the Prevention and Public Health Fund, which provides funds to combat preventable chronic diseases such as heart disease, cancer, stroke and diabetes, which account for 75 percent of the nation’s health spending. A recent report from Trust for America’s Health found that investing $1 in proven community-based programs could yield a five-year return of $5.60.

The fund is nothing less than an “investment in the future health of America,” according to Trust for America’s Health, and despite recent cuts, the fund will still provide billions of dollars over the next decade for injury and disease prevention.

## Decision charts course for road ahead

The survival of the law almost completely intact removes uncertainty among many in the public health community. It allows states to move ahead with exchanges that will allow those not covered by employer-sponsored care to buy health insurance. It lays out a way forward for the next few years that many said will put America on a path toward achieving a wholesale change in the way the country views health.

Among those praising the court’s decision were groups as varied as the American Academy of Pediatrics, Religious Coalition for Reproductive Choice and AIDS United.

“The ACA does more to improve America’s response to the HIV/AIDS epidemic than any piece of legislation since the Ryan White CARE Act,” said Kali Lindsey, director of legislative and public affairs for the National Minority AIDS Council. “Whether banning the practice of denying coverage to Americans with pre-existing conditions like HIV infection or caps on lifetime expenditures, this law will improve access to care for hundreds of thousands of people living with HIV.”

Tom Van Coverden, president and CEO of the National Association of Community Health Centers, said the part of the law that expands funding to community health centers will provide better access to care for all Americans.

“This means that in the years ahead, millions of newly insured people, and communities identified as medical shortage areas, will gain access to doctors, nurses and other health care professionals, and the quality, cost-effective primary and preventive services our health centers provide,” he said in a statement.

Amid the celebrations of the law’s constitutionality was a note of concern. The court ruled that states cannot be penalized for not participating in the law’s expansion of Medicaid. The expansion would mean that those making up to 133 percent of the federal poverty line — about $26,000 annually for a family of three — would be eligible to participate in Medicaid in 2014.

That part of the law would bring coverage to about 16 million to 17 million low-income people, with the federal government paying for almost all of the cost of adding those people. Now that states cannot be financially penalized, it is not clear whether those people will be covered. The governors of a number of states, including Texas, said in the wake of the decision that they will not participate in the Medicaid expansion.

Margaret Murray, CEO of the Association for Community Affiliated Plans, which represents 59 safety net health plans, called the Medicaid decision “unfortunate.”

“The law had promised to bring coverage to 16 million low-income people who live on a tightrope every day, one accident or illness away from financial ruin, and with few options for care beyond an emergency room,” she said. “It is now incumbent upon all states to step up, do the right thing and approve the expansion of coverage to working families with low incomes.”

Lamba Legal, which advocates for people with HIV/AIDS, called the Supreme Court victory incomplete as a result.

The overall decision, said Scott Schoettes, HIV project director for the group, will allow people to access medical advancements that have been out of reach because of their cost. But low-income people will not have that access if their states do not participate in the expansion.

“Our continuing challenge will be to make sure that states opt to expand Medicaid so that more low-income people, and particularly those with HIV, can get the health care they urgently need,” he said.

What the ruling will ultimately do for public health remains to be seen, but in his remarks after the decision, President Barack Obama said he believes it will make Americans more secure in their futures.

“When we look back five years from now, or 10 years from now, or 20 years from now, we’ll be better off because we had the courage to pass this law and keep moving forward,” Obama said.

![Figure3](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/42/6/17.1/F3.medium.gif)

[Figure3](http://www.thenationshealth.org/content/42/6/17.1/F3)

In Minneapolis, LaZya Smith, 5, stands near her mother as she addresses a June 29 rally held to celebrate the Supreme Court decision on the Affordable Care Act.

Photo by Elizabeth Flores, courtesy The Star Tribune/AP Images

*   Copyright The Nation’s Health, American Public Health Association