A large majority (https://www.kff.org/policy-watch/a-conundrum-majority-of-republican-voters-want-to-overturn-aca-but-keep-protections-for-people-with-pre-existing-conditions/) of voters, across political party identification, say they do not want the court to overturn the ACA’s protections for people with preexisting conditions, but there are strong partisan differences toward overturning the entire ACA. Maintaining protections for people with preexisting conditions ranks among the top healthcare issues. Health policy is complicated, and the average voter doesn’t have the time or inclination to read through all the legal arguments associated with the ACA.

Brought by attorneys general from 18 states and defended by attorneys general from 17 other states, the suit rose through lower courts, eventually making its way to the nation’s highest judicial body. The arguments surrounded the long-debated idea that only a state, not the federal government, can impose a sanction on a refusal to purchase health insurance because coverage is only a state issue, often referred to as an “individual mandate.” Defendants claimed they incurred punitive damages for being forced to purchase, or pay a penalty for not buying, federally required health coverage. The plaintiffs alleged (https://www.kff.org/health-reform/issue-brief/explaining-california-v-texas-a-guide-to-the-case-challenging-the-aca/) that millions of Americans in their respective states were also harmed by the mandated law.

Ultimately SCOTUS ruled (https://www.supremecourt.gov/opinions/20pdf/19-840_6jfm.pdf) that the plaintiffs did not have standing (i.e., sufficient stake in an otherwise justiciable controversy to sue) because “they have not shown a past or future injury fairly traceable to defendants.” In other words, no harm had or would be done by the plaintiffs paying for health coverage.

In a formal statement (https://www.whitehouse.gov/briefing-room/statements-releases/2021/06/17/statement-by-president-joe-biden-on-the-u-s-supreme-court-decision-upholding-the-affordable-care-act/), the White House reminded patients, nurses, and others that society has a “moral obligation to ensure that, here in America, health care is a right and not a privilege.”

Affordable Health Care for All

Obamacare was created to insure more Americans by expanding access to affordable healthcare plans. The extensive legislation provided thousands of pages on the many aspects and elements of the American system, including coverage, providers, specialists, medication, practice, and reimbursement. The sections most relevant to oncology nurses and patients with cancer include:

• Coverage of preexisting conditions (e.g., cancer)
• The ability to keep dependents covered through age 26 (i.e., children)
• Expansion of state Medicaid plans (e.g., older adults, financially struggling patients)

And in just 10 years, ACA has achieved so many of its goals:

• Provided healthcare coverage to 31 million Americans (https://aspe.hhs.gov/pdf-report/aca-related-coverage-ib) who were otherwise uninsured
• Covered (https://voice.ons.org/advocacy/aca-medicaid-expansion-improves-health-and-increases-access-to-care-for-young-adults) 1 million young adults (https://aspe.hhs.gov/pdf-report/aca-related-coverage-ib), improving their overall health, increasing access to care, and reducing out-of-pocket costs
• Improved (https://voice.ons.org/news-and-views/medicaid-expansion-coincides-with-earlier-colon-cancer-diagnosis-rates) cancer outcomes through earlier diagnosis

“All Americans continue to have a right to access affordable care, free of discrimination,” Health and Human Services (HHS) Secretary Xavier Becerra said (https://www.hhs.gov/about/news/2021/06/17/statement-hhs-secretary-xavier-becerra-us-supreme-court-decision-uphold-affordable-care-act-california-texas.html). “More than 133 million people with preexisting conditions, like cancer, asthma, or diabetes, can have peace of mind knowing that the health protections they rely on are safe.”

Challenged, but Still Constitutional

However, a 10-year litany of court system cases sought to reverse the law. The first was National Federation of Independent Business (NFIB) v. Sebelius. NFIB alleged that forcing people to purchase a product, in this case health insurance, was not under the U.S. Congress’ jurisdiction to levy. On June 28, 2012, SCOTUS upheld (https://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf) the constitutionality of the individual mandate requiring all citizens to have health insurance and the government’s right to tax those who do not comply.

Next, King et al. v. Burwell, Secretary of Health and Human Services, et al. challenged ambiguous wording about a tax credit for purchasing health coverage through state exchanges. The court found for the defendant, saying that U.S. Congress’s intent when drafting the legislation was to provide the tax credit as an incentive.

“The combination of no tax credits and an ineffective coverage requirement could well push a state’s individual insurance market into a death spiral,” Chief Justice John Roberts, for the 6-3 majority, wrote (https://www.supremecourt.gov/opinions/14pdf/14-114_qol1.pdf). “It is implausible that Congress meant the act to operate in this manner. It thus stands to reason that Congress meant for those provisions to apply in every state as well.”

In all three cases, SCOTUS repeatedly upheld ACA’s constitutionality. As a key promoter of expanded healthcare coverage during the Obama administration, in 2010 President Biden (serving as vice president under Obama at the time) uttered those famous words caught on an open mic about the passage of the bill being a big deal. He reiterated his support in a June 2021 tweet (https://twitter.com/potus/status/1405551328877744129): “With millions of people relying on the Affordable Care Act for coverage, it remains, as ever, a big deal. And it is here to stay.”

ONS Perspective

The Society’s formal health policy positions statements demonstrate ONS’s leadership in access to care for all, demanding that “all people should have access to comprehensive, affordable health care. Holistic quality cancer care requires access to healthcare professionals across specialties, and consumers must have access to a full choice of healthcare providers”—nurses included (https://www.ons.org/make-difference/ons-center-advocacy-and-health-policy/position-statements/access-quality-cancer). With its seat at many tables across the country from the local to national level, ONS is advocating for patient-centered, research-supported care coordination (https://www.ons.org/make-difference/ons-center-advocacy-and-health-policy/position-statements/access-quality-cancer) as the leading voice for oncology nurses in the policy arena.