On March 4, the Affordable Care Act (ACA) comes before the Supreme Court for the third time, and the stakes are as high as they were in 2012 when the law made its first debut. The question before the Court is whether the ACA’s tax credits and subsidies are limited only to consumers of state-run Marketplaces.
For the nine justices, the case is one of statutory interpretation and will turn on a few words and the amount of deference the government has in interpreting them. For the 4.5 million Americans currently insured through the federal Marketplace thanks to the ACA’s tax credits, the case is truly a matter of life and death.
A ruling in the negative, limiting the tax credits to only state-run Marketplaces, will turn the ACA on its head. The RAND Corporation predicts premiums would skyrocket 47 percent in the 34 states relying on Healthcare.gov. The impact on the number of uninsured would be staggering—to the tune of 9.6 million people losing coverage because they can no longer afford it.
Mohd, an immigrant from Bangladesh, and his family of six will be in those millions. The ACA’s tax credits made it possible for his family to afford coverage for the first time in years, at just $100 a month. Without the credit, his monthly premium will rise to $1,500, and eat up half his yearly income. No longer will Mohd’s children have access to basic preventive care so they can stay healthy. And the family will once again live in perpetual fear at the thought of becoming sick.
Sione knows all too well what that fear feels like. A landscaper by trade, he tried to ignore the constant dizziness and weakness he was feeling. Uninsured with no way to afford routine health care, Sione simply went without; even after he was diagnosed with diabetes. When the ACA’s tax credits finally provided him coverage he could afford, he got control of his diabetes. Take away the tax credits and he will have to start skipping medications again.
The overwhelming majority of Americans who enrolled though the federal Marketplace did so with the help of tax credits, just like Mohd and Sione. And because most uninsured Americans live in these states, eliminating the tax credits will be devastatingly unequal. While racial and ethnic minorities make up only 40 percent of the U.S. population, they account for half of the uninsured. More than 2.4 million Asian Americans, Native Hawaiians and Pacific Islanders, for example, were uninsured before the ACA. Three of the five states with the largest Asian American, Native Hawaiian and Pacific Islander populations—Texas, Florida and New Jersey—rely on the federal Marketplace and would feel the brunt of an adverse ruling.
Hwang lives in New Jersey, and like many middle class Americans, lost his job and health insurance for his entire family after the recession. The family crossed their fingers every day for four years, knowing that a medical emergency could break their finances. It wasn’t until the ACA kicked in and they got coverage with the help of tax credits that his wife even realized she was battling a serious infection.
Meanwhile, the ACA’s tax credits literally saved Pastor Han’s life. One month after getting covered, he had a serious heart attack that rushed him to the emergency room and into surgery. Without coverage, he would have tried to wait out the chest pain and coughing, not realizing he was having a heart attack.
Eliminating the tax credits won’t just put these American lives in peril, it will erode some of the largest coverage expansions in decades. The National Center for Health Statistics reports that 10 million people have gained coverage since before the start of open enrollment. The number of Americans without health insurance is now at near record lows. The wrong outcome in King would topple that.
Turning the insurance market upside down and rendering the ACA’s coverage expansions meaningless is not what Congress intended. The tax credits function in sync with numerous other provisions of the ACA and are necessary to ensure that insurance markets and coverage pools are robust. The tax credits are a crucial element of the law and are the method by which the law works: drastically reducing the nation’s uninsured by expanding coverage to millions of people who otherwise would never be able to afford it.
When the Supreme Court makes its decision in King, it will also decide the fate of millions of Americans. Let’s hope the stories of Mohd, Sione, Hwang and Han are on the justices’ minds.
Chin is president and CEO of the Asian & Pacific Islander American Health Forum (APIAHF), the nation’s oldest and largest organization working to advance the health and well-being of Asian Americans, Native Hawaiians and Pacific Islanders (AAs and NHPIs). APIAHF filed the only amicus brief before the Supreme Court in King v. Burwell detailing the impact of the ACA’s tax credits and subsidies on AAs and NHPIs.