The Supreme Court once again affirmed the legality of the Affordable Care Act. This time the court's answer is unambiguous. As Chief Justice John Roberts wrote: "Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them."
The 6-3 ruling means that people who buy insurance using tax credits as subsidies – some 6.4 million people – will continue to do so regardless of where they live. Thirty-four states have not set up health insurance exchanges and sao consumers must purchase plans through a federal exchange.
At the White House, President Barack Obama said "the Affordable Care Act is here to stay."
But Congress has other ideas. The House has voted to repeal the Affordable Care Act some fifty times and this is certain to again be an election year issue in 2016. This ruling will also increase the political pressure for conservatives to try and derail the law using the budget, making it much more difficult for Congress and the Obama administration to reach a deal over federal spending next year.
There is an interesting twist on this case for American Indian and Alaska Native consumers. Early on both supporters in Congress and in the Obama administration decided to play up the portion of the law that exempted Native Americans from the mandatory insurance requirements. The idea was that delivery of health care is seen as a treaty right, so it was impossible to force Native Americans to buy insurance. But the problem is the Indian health system does not have adequate funding – and the best course for improving that revenue stream is to sign up more Native Americans for some kind of insurance through a job, Medicaid, Medicare, Childrens' Health Insurance Program, or these health insurance exchanges.
According to a report by the Kaiser Family Foundation, nearly one in three American Indians and Alaska Natives is uninsured and most have far less access to employer-based insurance than other Americans. "Less than four in 10 American Indians and Alaska Natives have private coverage, compared to 62 percent of the overall non elderly population," Kaiser reported. "Medicaid helps fill this gap, covering one in three non-elderly American Indians and Alaska Natives. Medicaid also provides key financing for IHS providers and has special financing rules and protections for American Indians and Alaska Natives. However, nearly one in three nonelderly American Indians and Alaska Natives remains uninsured."
One way to improve that insurance rate is to encourage more American Indians and Alaska Natives to take advantage of subsidized plans purchased through exchanges. There are, for example, plans for a family of four earning up to $70,650 (or $88,300 in Alaska) that have no cost, including deductibles and co-pays. If a family earns more than that amount, an insurance plan purchased through the exchange could still be eligible for no out-of-pocket costs when using the Indian health system. Native Americans can also sign up for the insurance plans every month, instead of during limited open enrollment periods.
Jim Roberts, a policy analyst for the Northwest Portland Area Indian Health Board, said it's difficult to get data from the federal and state exchanges. However one report, that Roberts said is "suspect," does have some data showing that approximately 22,000 American Indians and Alaska Natives in the federal exchange have received cost-sharing benefits. "What's interesting about this report is that 41,626 persons were determined eligible for cost-sharing reductions, however only 22K were covered by a selected plan. A very low take up rate despite high eligibility. Indian participation is a real problem," Roberts said, both in the state and federal exchanges.
Perhaps that should be the outcome of the court's ruling Thursday: A new emphasis on making certain that American Indians and Alaska Natives take advantage of every dollar eligible under the law. This would be one way of boosting funding for Indian health clinics and hospitals. And this money does not require appropriations from Congress or approval from a state (as is the case with Medicaid).
As he celebrated the court's ruling Thursday, President Obama said: "On March 23, 2010, I sat down at a table in the East Room of the White House and signed my name on a law that said, once and for all, that health care would no longer be a privilege for a few. It would be a right for everyone."
But that right also requires action. Action from the administration informing American Indians and Alaska Natives about the benefits; as well as action from every clinic and patient to make sure we all have the insurance we're entitled to receive under the law. Call it, the pre-paid, Treaty Insurance plan.