With the greatest number of residents in the nation receiving financial aid from the government to buy health insurance under the Affordable Care Act, Florida averted a potential crisis Thursday when the U.S. Supreme Court ruled by a 6-3 vote that millions of Americans can continue to receive subsidies through the federally run exchange at HealthCare.gov.
Ruling in the case of King v. Burwell, the Supreme Court upheld the Obama administration’s interpretation of the health law that allows billions of dollars in health insurance subsidies — including an estimated $389 million a month for Florida residents — to be distributed in the 34 states where the federal government operates the insurance exchange because those state decided against running their own.
About 6.4 million Americans, including an estimated 1.3 million Floridians, receive financial aid to make their health plans affordable under the law, according to government estimates.
Many expressed relief following the court’s ruling.
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Celia Maluf, a Miami Pilates instructor who gained health coverage for the first time in nearly a decade because of the health law known as Obamacare, had traveled to Washington, D.C., in March to hear the oral arguments. When she heard the news Thursday in her Coral Gables studio, she embraced a nearby client, overcome by emotion.
“I started jumping and crying like a fool and it was lovely,” she said. “It feels like I won the Lotto or something.”
Maluf, 60, lost her employer-sponsored coverage in 2005 and remained uninsured until she bought a plan on the ACA exchange in 2013. At $217 a month, her insurance has helped cover exams with various physicians — and even catch a precancerous skin lesion.
Waiting for a decision from the court cost her sleepless nights, Maluf said, when she wondered if she may have to forgo insurance again.
“It’s not a luxury item,” she said. “It’s a needed item that represents so much in my life.... It feels that justice works in this country.”
Writing for the Supreme Court’s majority, Chief Justice John Roberts acknowledged the strength of the challengers’ arguments about “the plain meaning” of the health law — that the language in the law prohibits subsidies to residents of states where the federal government, rather than the state, runs the exchange.
But the majority pivoted away from an isolated reading of the six words at the heart of the plaintiff’s case — “an Exchange established by the state” — and focused instead on the broader context of the law.
“In this instance, the context and structure of the Act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase,” Roberts wrote for the majority.
Concluding the opinion of the court, he wrote: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”
Dissenting were Justices Antonin Scalia, Clarence Thomas and Samuel Alito. In a scathing rebuke of the majority, Scalia made clear his deep displeasure in a 20-page explanation.
“Words no longer have meaning if an Exchange that is not established by a State is ‘established by the State’,” he wrote.
Scalia accused the court’s majority of performing “somersaults of statutory interpretation” when it comes to the health law. Referencing the court’s 2012 decision upholding the constitutionality of the law’s mandate requiring all eligible Americans to buy health insurance, he warned that future litigants would cite the court’s precedents endlessly, “to the confusion of honest jurisprudence.’’
In concluding the dissent, Scalia wrote: “We should start calling this law SCOTUScare. ... This Court’s two decisions on the Act will surely be remembered through the years.’’
Outside the Supreme Court in Washington, D.C., crowds of supporters of the health law known as Obamacare hoisted signs and led chants cheering the decision.
Speaking from the White House Rose Garden, President Barack Obama sounded a triumphant note over the court's ruling.
“The Affordable Care Act is here to stay,” he said.
Calling healthcare a “right for all” and not “a privilege for a few,” Obama said millions of Americans would have become uninsured had the court struck down the subsidies designed to make coverage more affordable for low- and middle-income Americans.
Repeating several times that “the law is working,” Obama seemed aware of the central role the ACA will play in his legacy as president.
“For all the repeal attempts,” he said, “this law is now helping tens of millions of Americans, and they've told me that it has changed their lives for the better.”
Yet Obama also acknowledged the political resistance that remains to the law. He singled out states like Florida that “for political reasons,” he said, have resisted one of Obamacare’s most significant coverage provisions — expanding eligibility for Medicaid to nearly all low-income adults.
“I'm going to work as hard as I can,’’ Obama said, “to convince more governors, more legislatures to take advantage of the law... and expand Medicaid.”
Dianne and Rick Elkin, residents of Central Florida, count themselves among those who would have become uninsured had the court ruled for the plaintiffs — a potentially life-threatening proposition.
Rick Elkin is in stage-four liver failure, Dianne Elkin said, and the married couple are living on disability payments and a heavily subsidized Obamacare plan. Had the court ruled against the subsidies, Dianne Elkin would have been forced to sell their house to afford her husband’s health insurance.
“Without this plan,” she said, “he would die.”
Elkin’s comments echoed the reaction of U.S. Health and Human Services Sec. Sylvia Burwell, the defendant in the Supreme Court case. Burwell said millions of Americans can “sleep easier” knowing they can still afford health insurance.
“Millions more won’t have to worry about an upward spiral in their premiums because of today’s decision, even if they didn’t buy their insurance through the Marketplace,’’ she said in a written statement.
“People’s lives have been changed and even saved because they have health insurance — many for the first time,’’ she said. “They have coverage that can keep them healthy and provide quality care when they are sick.’’
In Florida, as in the rest of the nation, reaction to the Supreme Court’s ruling reflected strong opinions for and against the health law. Healthcare policy analysts say Obamacare still faces challenges from Congress’s efforts to repeal all or part of the law.
U.S. Senator Marco Rubio, a Florida Republican campaigning for president, reacted by calling Obamacare a “bad law.”
“I disagree with the Court’s ruling and believe they have once again erred in trying to correct the mistakes made by President Obama and Congress in forcing Obamacare on the American people,'' Rubio said in a written statement.
“Despite the Court’s decision, Obamacare is still a bad law that is having a negative impact on our country and on millions of Americans. I remain committed to repealing this bad law and replacing it with my consumer-centered plan that puts patients and families back in control of their health care decisions.”
Former Gov. Jeb Bush, a 2016 Republican presidential candidate, released a video statement, expressing his displeasure with the court.
“I am disappointed by today’s Supreme Court ruling in the King v. Burwell case. But this decision is not the end of the fight against Obamacare,’’ Bush said.
Florida advocates of the law, including Karen Egozi, chief executive of the Epilepsy Foundation of Florida, which has been awarded two federal grants to train and hire counselors or navigators to help consumers, noted that the group has helped more than 60,000 residents understand their options under the law.
“Our navigators have seen how much Florida's families benefit from affordable health coverage,’’ Egozi said in a written statement. “Today's Supreme Court decision will allow those families, and eight million more across America, to continue getting the healthcare they deserve."
Leah Heinz, CEO of Florida Chain, a statewide consumer healthcare advocacy group, added that the ACA "is working as intended, and today’s decision should finally put an end to efforts to hijack or derail this historic and law that is saving lives.”
Florida is one of 34 states that has not established an insurance exchange under the health law and instead relies on the federally run marketplace at HealthCare.gov. However, two of those states, Delaware and Pennsylvania, have received conditional approval to operate state-based exchanges in 2016.
Washington, D.C., and 16 states have established insurance exchanges or a hybrid model in partnership with the federal government. Residents of those states would not have been affected by a Supreme Court ruling for the challengers.
As of March 31, more than 1.4 million Floridians were enrolled in a health plan through the federally run exchange, with about 1.3 million of them receiving financial help from the government to make their insurance more affordable, according to government estimates.
On average, those Floridians received a premium tax credit of $294 per person in March, reducing their monthly payment for health insurance to an average of $82, according to government data.
South Florida, in particular, was an enrollment powerhouse. Combined, sign-ups in Miami-Dade, Broward, Monroe and Palm Beach counties topped those in 47 entire states. Miami-Dade County alone enrolled more people than 43 states: about 400,000 as of Feb. 22.
The country’s top enrollment ZIP codes were also in South Florida. Hialeah claimed the No.1 ZIP code in the country — 33012 — along with three others in the top 10.
Miami Herald writer Rosalind Adams contributed to this report.
Follow @MHhealth for health news from South Florida and around the nation. This story was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.
Key quotes from the ruling:
From Chief Justice John Roberts majority opinion:
“The upshot of all this is that the phrase ‘an Exchange established by the State’… is properly viewed as ambiguous. The phrase may be limited in its reach to State Exchanges. But it is also possible that the phrase refers to all Exchanges — both State and Federal — at least for purposes of the tax credits.”
“The Affordable Care Act contains more than a few examples of inartful drafting.... Congress wrote key parts of the Act behind closed doors, rather than through ‘the traditional legislative process’ .... As a result, the Act does not reflect the type of care and deliberation that one might expect of such significant legislation.”
“The statutory scheme compels us to reject petitioners’ interpretation because it would destabilize the individual insurance market in any State with a Federal Exchange, and likely create the very ‘death spirals’ that Congress designed the Act to avoid.”
"… Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter."
From Justice Antonin Scalia’s dissent:
“This Court, however, concludes that this limitation would prevent the rest of the Act from working as well as hoped. So it re-writes the law to make tax credits available everywhere. We should start calling this law SCOTUScare.”
“The Court’s next bit of interpretive jiggery-pokery involves other parts of the Act that purportedly presuppose the availability of tax credits on both federal and state Exchanges.”
“Under all the usual rules of interpretation, in short, the Government should lose this case. But normal rules of interpretation seem always to yield to the overriding principle of the present Court: The Affordable Care Act must be saved.”
“This Court holds only the judicial power—the power to pronounce the law as Congress has enacted it. We lack the prerogative to repair laws that do not work out in practice, just as the people lack the ability to throw us out of office if they dislike the solutions we concoct.…”