Immediate reactions to the King v. Burwell decision

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Today, in a six-to-three decision, the Supreme Court ruled in favor of the Obama administration in King v. Burwell to preserve access to premium tax credit subsides for eligible consumers in all states, not just those that operate state-run insurance exchanges.

Below are immediate reactions to the Supreme Court's decision from several healthcare industry executives, organizations and experts.

This piece will be continually updated as more comments become available.

John Arensmeyer, founder & CEO of Small Business Majority: "We're pleased the U.S. Supreme Court ruled today to uphold the Affordable Care Act's provision that allows consumers in states with federally-run health insurance marketplaces to receive federal tax credits to help offset the cost of insurance.

The Supreme Court's decision protects the millions of small business owners, employees and self-employed freelance entrepreneurs from losing the valuable health insurance they have secured in the past 18 months. Moreover, eliminating the credits would have led to a return of 'job lock,' which shackled many would-be entrepreneurs to jobs working for others rather than starting their own businesses. Employment and access to affordable health insurance historically have been tightly linked. That linkage pressures individuals to seek out and remain in jobs that provide affordable health insurance, even if they would otherwise choose to start their own business or pursue a more attractive job opportunity with a growing small business. ... The health insurance marketplaces are the most important component of the Affordable Care Act for entrepreneurs, and it's critical they are kept as robust as possible. "

Avalere Health (Washington, D.C.): "Affordable Care Act implementation returns to normal following today's ruling but debate over the law is likely far from over. Congress may still pursue strategies to alter the Affordable Care Act, and the debate over reform is likely to reignite as part of the 2016 presidential race.

Congress is still likely to consider repeal of the medical device tax and the Independent Payment Advisory Board, as well as changes to the employer mandate and the Cadillac Tax."

Barclay Berdan, CEO of Texas Health Resources: "The Supreme Court's decision in King v. Burwell is good news for more than 1 million Texans who received subsidies to buy insurance through the marketplace. It's also good news for every other insured Texan because the larger pool of insured people helps control the costs of rising premiums. With access to coverage, people are more likely to seek care in a timely manner. We know that access to prevention and early intervention can improve wellbeing and overall health. By catching potential health problems early, we can also better manage the cost of care."

Eric Bieber, MD, president and CEO of Rochester (N.Y.) Regional Health System: "While today's Supreme Court ruling does not directly impact residents of New York State, it is welcome news for millions of residents in other states who will continue to be eligible for federal subsidies to help pay for their healthcare coverage. The ruling ensures that these individuals have access to care when they need it.

Across the country, the ways in which we provide and pay for healthcare continue to evolve, and it our hope that the move towards value-based care — care that is paid for based on quality outcomes — continues. Rochester Regional Health stands committed to providing our patients with the best value-based care available in their local communities."

Sylvia Matthews Burwell, secretary of U.S. Department of Health and Human Services: "Today's Supreme Court decision confirms that the Affordable Care Act's tax credits are available to all eligible Americans no matter where they live. Americans in all 50 states and the District of Columbia can continue to rely on the security and peace of mind that come with affordable, quality healthcare coverage.

Over six million Americans and their families will sleep easier knowing they will still be able to afford health coverage. 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. And the law's financial assistance will be available in the next open enrollment so that others can benefit as well.

The Affordable Care Act is working to improve access, affordability and quality.

That is the story I hear as I travel across this country. People's lives have been changed and even saved because they have health insurance — many for the first time. They have coverage that can keep them healthy and provide quality care when they are sick.

The Affordable Care Act also strengthens protections for almost every American with health insurance. People with pre-existing conditions can no longer be denied coverage or charged higher premiums. Critical preventive services, like immunizations and certain cancer screenings, are available at no additional cost. Since parents can keep their children on their health insurance policies up to age 26, young Americans can stay in school or find their first job without worrying about their coverage. And your health premiums can no longer be higher just because you are a woman.

I hope that this positive decision will do what the American people want us to do -- focus on the substance and turn to building on the progress we have made. They want us to move forward to provide more Americans with affordable access to quality coverage and create a healthcare system that improves the quality of care and spends our dollars more wisely."

Bill Carpenter, chairman and CEO of LifePoint Health (Brentwood, Tenn.): "We are very pleased with the Supreme Court ruling. Congress clearly intended to help all Americans have greater access to quality healthcare services through affordable health insurance coverage, regardless of the state in which they live. We are pleased that the Court upheld the spirit and intent of the Affordable Care Act enacted by Congress.

LifePoint Health serves the needs of many people living in small, rural communities across the nation, regardless of their healthcare coverage or ability to pay. We are grateful that those who have secured affordable health insurance through the state exchanges will have peace of mind knowing that their coverage — and access to care — will continue.

We hope this ruling will encourage state governments that haven't already done so to embrace the intent of the law and expand their state Medicaid programs."

Andy Carter, president and CEO of The Hospital & Healthsystem Association of Pennsylvania: "HAP and the Pennsylvania hospital community commends the U.S. Supreme Court for its decision that financial subsidies will continue to be available to support insurance coverage for individuals and families in states with federally-facilitated health exchanges, including Pennsylvania.

About 81 percent of Pennsylvanians who have secured health coverage through the federal marketplace receive these vital subsidies — that is more than 380,000 Pennsylvanians who rely on this financial support to keep their and their family's necessary health coverage.

HAP is pleased that the individuals who rely on subsidies to afford their health insurance will not be forced to make difficult decisions, drastically altering their family's health and finances. Fortunately, the ruling supports uninterrupted and affordable coverage that is critical to both individuals and providers in Pennsylvania."

Pamela F. Cipriano, PhD, RN, president of the American Nurses Association: "We are gratified that the Supreme Court ruling will avoid the loss of subsidies that have allowed millions of people to get healthy and stay healthy. The Supreme Court has spoken. Now it's time to finish the work of ensuring Americans get the healthcare they need by expanding Medicaid."

Dan Durham, interim CEO of America's Health Insurance Plans: "With the certainty provided by the Supreme Court's decision, now is the time to focus on what matters most to consumers — ensuring access to affordable coverage and high-quality healthcare. Health plans will continue to lead in advancing this goal."

Steve Friedman, shareholder and co-chair of the Employee Benefits Practice Group at Littler Mendelson: "The Court's decision elevated Congressional intent and an admitted concern about the preservation of the Affordable Care Act over what many claimed was clear statutory language. ... This seemingly plain statutory language could disallow tax subsidies in those 36 states if the presence of a state-run exchange was found to be necessary for a subsidy to be provided. The Supreme Court admitted that if the statutory language was clear, it would need to follow it and disallow subsidies in these states. However, the Court found the language to be ambiguous, finding that if an State chooses not to establish an exchange, then the ACA requires the Secretary of Health and Human Services to establish 'such Exchange.' This 'ambiguity' then allowed the Court to look not just at the statutory language but the 'overall statutory scheme.' It could then find that Congress intended the ACA to allow subsidies to more than those who live in states which established Exchanges.

The Court, in Justice Scalia's view, expressed in a dissenting opinion, distorted the plain reading of the ACA. Justice Scalia stated that 'words no longer have meaning if an Exchange that is not established by a State is 'established by the State.' The decision will be seen by many as a case of legislative intent trumping statutory language." 

Annette Guarisco Fildes, president and CEO of the ERISA Industry Committee: "With the legal case settled, Congress should use this opportunity to repeal the burdensome and unnecessary taxes, mandates and reporting requirements imposed by the ACA. Specifically, we want Congress to repeal the 40 percent healthcare excise tax, the employer mandate and all the related reporting requirements."

Lily Eskelsen García, president of the National Education Association: "Today's decision by the Supreme Court in King v. Burwell will let millions of Americans breathe a little easier knowing that their health insurance is secure and will remain affordable. The subsidies provided by the Affordable Care Act help increase school children's access to quality health insurance and medical care." 

Chris Van Gorder, president and CEO of Scripps Health (San Diego): "I thought the decision would be split with one vote making the difference one way or the other, but the decision today was overwhelming in support of the ACA with both Roberts and Kennedy supporting the four liberal members of the court with the three conservative members voting against.

I think it's notable that Chief Justice Roberts wrote the opinion on behalf of the majority. This puts to an end the question of whether or not the ACA will be the law of the land or not and brings a sense of security for all those insured through state and federal exchanges — subsidized or not — and for all of their providers. I hope we can all put the issue behind us now so we can come together to build a higher-quality and more cost-effective healthcare system for all Americans fair to patients and providers alike."

Jon Greenbaum, chief counsel of the national Lawyers' Committee for Civil Rights Under Law: "The Supreme Court has rightly recognized disparate impact claims and the important role they play in promoting fairness and inclusion in American society. Focusing on the effects of a policy or practice, rather than the intent behind it, is the most effective way of dismantling structural barriers to equal opportunity and is necessary because discrimination is often subtle and covert."

Marielena Hincapié, executive director of National Immigration Law Center: "Today's decision, both legally accurate and morally sound, means that millions of families will no longer be at risk of losing the ability to see a doctor when they are sick. Because of the Affordable Care Act marketplace, more than 10 million people live with the security of access to affordable healthcare, and stripping them of such care is both politically — and legally — indefensible." 

Douglas Hoey, CEO of National Community Pharmacists Association: "Community pharmacists are critical front-line providers of care to many Americans, particularly those in underserved rural and inner-city areas. Every day they help patients, with or without insurance, obtain the prescription drugs or other care that they need. While the political debate over U.S. healthcare will continue, today's ruling provides a degree of clarity for community pharmacists as they continue to help patients navigate a complicated healthcare system."

Land of Lincoln Health (Chicago): "Since Land of Lincoln Health's founding as a non-profit health insurance CO-OP, one of our central beliefs has been that all Americans have the right to access affordable, high-quality health insurance. Therefore, we're pleased with the Court's decision to uphold the intent of the Affordable Care Act.

Most importantly, we recognize the importance of these subsidies to some of our members, often the most vulnerable in our communities. We are both thrilled and relieved that those individuals and families will be able to maintain coverage for their essential healthcare needs. This ruling may prevent some families from having to make the intolerable decision between medical care or food and shelter."

Bill Melville, market analyst for Decision Resources Group: "By upholding the subsidies, the exchange markets won't see major changes for 2016. This won't be the last legal challenge to the law, but it will likely be the last big one."

Margaret A. Murray, CEO of the Association for Community Affiliated Plans: "We're glad the Court applied common sense and found for the defendants. It's our hope that this ruling brings to a close efforts to destabilize the healthcare system through the courts, and we can instead focus our collective energies on refining and improving the way healthcare is paid for, the way health coverage is bought, and the way care itself is delivered."

Debra L. Ness, president of the National Partnership for Women & Families: "Our nation will be healthier and families stronger and more economically secure because the U.S. Supreme Court ruled against the challengers in King v. Burwell today. This case posed a direct threat to the health insurance subsidies that make coverage affordable for the roughly 6.4 million people in 34 states who enrolled in coverage through the federal marketplace. In refusing to undermine the law, the Court acted wisely and in the country's best interests. We hope this decisive 6-3 ruling finally puts an end to politically motivated, grossly irresponsible attacks on the Affordable Care Act.

Women, in particular, can breathe a sigh of relief today. Women are 54 percent of those purchasing coverage through the federal marketplace and would have been hurt the most by an adverse ruling." 

Megan Neuburger, managing director at Fitch Ratings: "The court's decision to side with the Administration in King v. Burwell is ultimately positive for hospitals and health insurers as it keeps the status quo, which has been beneficial to them under the ACA. While legal and political challenges to the ACA remain, the court's decision underscores the uphill battle plaintiffs will face in the remaining legal challenges like those to the employer mandate, contraception coverage and others. Today is a sigh of relief for the healthcare industry, and part of the good news is that we shouldn't have to hold our breath for quite as long as the remaining issues get resolved."

Richard Parker, MD, Former CMO at Beth Israel Deaconess Care Organization (Westwood, Mass.), and future CMO at Arcadia Healthcare Solutions (Burlington, Mass.): "In the wake of the King v. Burwell ruling, my focus continues to be on the same thing it always has been, and that's on how we can improve the quality of care at the same time we reduce costs. Having spent three decades in an industry that is undergoing massive transformations and shifts, I applaud the direction of the Affordable Care Act to provide health coverage to more citizens. With this ruling it's time for providers to more deeply understand the risks, costs and health of the patients they care for, especially as we will see an increase in patients with exchange-based insurance. This is a game-changer, as it's no secret that by in large the patients who have exchange-based insurance are generally higher risk, and therefore, costlier than others. If the mission is to reduce overall healthcare expenses while improving care, it's foundational for providers to focus on how to attain good quality patient data so everyone can understand the real patient risks and subsequently make the correct clinical care choices."

Pete Pavarini, partner in healthcare at Squire Patton Boggs and current president of the American Healthcare Lawyers' Association: "Having survived two major challenges, the ACA represents the path forward. Now, we need to roll up our sleeves and get to work fixing the problems that still vex our healthcare system." 

J.D. Piro, senior vice president at Aon and leader of Aon's Health Law Group: "This case was the last major judicial hurdle that the Affordable Care Act had to clear before full implementation. Now employers have to focus on reporting on compliance with the individual and employer mandates for 2016, along with determining the projected impact of the ACA's health plan excise tax in 2018. They will need to find the right combination of strategies to ensure compliance and reduce their exposure."

Robert Projansky, partner with Proskauer and head of the firm's Healthcare Reform Task Force. "The Supreme Court ruled in favor of the Federal government, holding that although the language in Code Section 36B is ambiguous, the ACA's overall statutory scheme and the structure of Code Section 36B itself indicate that premium assistance is not limited to individuals purchasing coverage on state-run marketplaces. 

Despite ambiguity in the statute, the Supreme Court rejected its typical approach (under Chevron) whereby the Court analyzes whether an agency interpretation is reasonable in the face of an ambiguous statute. The Court instead conducted its own analysis as to the proper interpretation of the statute because of it viewed this as an issue of such 'deep economic and political significance' that Congress would not have delegated it to regulators. ...

Notable in the decision was the disagreement between the majority and the dissent as to when the purpose of the statute and the context in which particular provisions appear matters relative to the explicit words of the statute. 

One wonders whether there will ever be another Supreme Court opinion that uses the words 'pure applesauce' as a sentence."

Chas Roades, chief research officer at The Advisory Board Company: "The decision is a clear win for the coverage expansion goals of the ACA. With the Court's ruling, providers in the 34 states using the federally facilitated exchanges will avoid the negative financial impacts that would have been expected with a predicted loss of coverage among 8 million to 9 million enrollees in the individual market. Furthermore, the decision provides additional stability to the marketplace, which may in turn support increased interest by participating plans and consumers. The Congressional Budget Office continues to predict rapid growth on the exchanges to about 25 million consumers by 2017, and the impact of the decision was evident in a steep increase in healthcare stocks this morning (particularly the for-profit hospital sector). 

Ultimately, we believe the exchanges are on firmer ground as a source of coverage for individuals and possible employee populations, and the federal exchange provides a more secure backstop to the state-based exchanges in case they encounter difficulties. We also expect that the enhanced stability around coverage means the administration will continue aggressively with is delivery and payment reform initiatives, and providers should maintain current course and speed with strategies related to the implementation of the ACA."

Trish Riley, executive director of the National Academy for State Health Policy: "With their decision today, the Supreme Court has protected coverage for 6.4 million Americans and avoided a crisis for states and their insurance markets, had the insurance subsidies been eliminated. The Court recognized the ACA was built on a state foundation and reaffirms whether a state chooses to establish a state exchange or not, affordable healthcare remains accessible for its residents.

The wait-and-see period is over and now states can move forward." 

Jay Sekulow, chief counsel of the American Center for Law and Justice: "This decision is disappointing and troubling. Unfortunately, the majority of the Court failed to apply the law as written. The Court instead rewrote the law, something it did not have the constitutional power to do. It is troubling that the high court backed the Obama Administration's overreach in its ongoing effort to rewrite or suspend portions of the ACA, in violation of the separation of powers. The Court clearly over stepped its authority. That is reflected by Justice Scalia in this line from his dissent: 'We should start calling this law SCOTUScare.'"

Scott P. Serota, president and CEO of Blue Cross Blue Shield Association: "Today's Supreme Court ruling ensures that millions of Americans can receive financial assistance from the government to help them continue to afford their health insurance coverage. Blue Cross and Blue Shield companies are committed to providing quality, affordable coverage community by community, nationwide, and we will continue in that long tradition. ... There is still more work to be done to make healthcare more affordable." 

Bruce Siegel, MD, president and CEO of America's Essential Hospitals: "America's Essential Hospitals praises today's U.S. Supreme Court decision, which maintains access to vital healthcare services for millions of Americans and supports the hospitals that care for our most vulnerable patients.

"As many as 6 million people stood at risk of losing coverage if the court ruled against premium subsidies. With its decision, the court keeps coverage within reach for individuals and families who otherwise have few affordable options to pay for care they need. ... Essential hospitals also welcome the decision, which reduces uncertainty about uncompensated care and creates greater stability for these hospitals as they work to meet their commitment to serving low-income people and others in need."

Steven J. Stack, MD, president of the American Medical Association: "The American Medical Association is relieved that today's Supreme Court decision will allow millions of patients to continue accessing the healthcare they need and deserve.

Physicians know that the uninsured live sicker and die younger so the AMA has been a leading voice in support of expanding health insurance access to ensure patients can get the care they require.

The subsidies upheld today help patients afford health insurance so they can see a doctor when they need one and not have to wait until a small health problem becomes a crisis. The subsidies provide patients with peace of mind that they will not risk bankruptcy should they become seriously ill or injured and experience catastrophic healthcare costs.

With this case now behind us, we hope our country can move forward and continue strengthening our nation's healthcare system."  

Anthony Tersigni, EdD, President and CEO of Ascension (St. Louis): "We are delighted that the Supreme Court has affirmed the Affordable Care Act and with it our ability to deliver personalized and compassionate care to those that need it. This will strengthen the health and well-being of the individuals and communities we are privileged to serve."

Tevi D. Troy, president of the American Health Policy Institute: "As a result of this decision, the insurance subsidies will be preserved for otherwise eligible purchasers of health insurance under the ACA without regard to whether they purchase their insurance on a federally established or a state established health insurance exchange. This is not, however, the end of the conversation about the ACA.

Today, 169 million Americans currently receive healthcare from their employer, but it is questionable if this trend will continue in the years to come with the increasingly lack of affordability of average family premiums and deductibles as well as the looming healthcare excise tax, which will hit the average value plan come 2031.

As a result of these and other uncertainties, we will continue to see a lot of discussion on the ACA leading up to the 2016 presidential election. Republicans will now turn their focus to 2016 and getting one of their party's candidates elected as president and attempting to repeal or significantly reform the law. Democrats, on the other hand, may see the case as a tipping point for the law's acceptance and the discussion could then turn to making badly needed changes to the law. Either way, the climate may be ripe for ACA changes in 2017, regardless of which party wins the White House."

Cori Uccello, senior health fellow at the American Academy of Actuaries: "The ACA's premium subsidies work together with the individual mandate as incentives for even individuals in good health to obtain coverage. Had the court's majority decided differently, the federal-marketplace states would be facing significant disenrollment of those who cannot afford insurance without the subsidies, and the consequences of that could have threatened the viability of those markets. In the loss-of-subsidy scenario, adverse selection would have been a serious concern, as relatively higher-cost individuals would have retained coverage, increasing average costs and premiums."

Rich Umbdenstock, president and CEO of the American Hospital Association: "The AHA welcomes today's Supreme Court decision. There were more than 6 million good reasons for it, because it ensures continued access to health insurance subsidies for so many Americans. In the short time the subsidies have been available, hard-working people who are sick, need care for chronic conditions, or want preventive care have been able to seek care more easily. Most significantly, providing access to primary and preventive care helps improve the health and well-being of individuals, family and communities. 

Lawrence Vernaglia, chair of Foley & Lardner's Healthcare Industry Team: "King v. Burwell was one more test of whether the Affordable Care Act would be able to stay and deliver on the promises that Congress and the President had in mind when they negotiated it, and today it passed the test. The ACA lives to fight another day, and will continue to provide patients with access to healthcare anywhere in the country, regardless of where they live and regardless of how that state chose to implement changes. However, the system has to change to make sure patients continue to receive insurance at affordable premiums."

Maryjane A. Wurth, president and CEO of Illinois Hospital Association: "The Illinois Hospital Association applauds today's U.S. Supreme Court decision upholding the legality of subsidies for hundreds of thousands of Illinoisans and millions of Americans that have enabled them to obtain health insurance coverage under the ACA.

Because of these subsidies, more than 230,000 low- and moderate-income Illinoisans are able to afford health insurance, ensuring that they have access to the healthcare they need when they need it. These Illinoisans now receive more than $49 million a month in subsidies (nearly $600 million on an annualized basis)."

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