Supreme Court Upholds Affordable Care Act: Impact On Ambulatory Care Settings

The U.S. Supreme Court decision on the case known as the National Federation of Independent Business v. Sebelius came on the last day of the Court's 2011-2012 term. Twenty-five states brought this case to the Supreme Court. Two states both challenged and supported the Patient Protection and Affordable Care Act (PPACA), 11 states supported it, and 12 states took no position on it. There were two major decisions provided by the Justices.

First, a majority of the Court Justices (5 to 4) upheld the Individual Mandate, saying that the Mandate is "a constitutional exercise of Congress' power to tax" (The Kaiser Family Foundation, 2012a, p. 4). As discussed in the May/June issue of this column (Haas, 2012), this will have an impact on approximately 1% of the U.S. population and will go into effect in 2014. There will be no effect on the rest of the U.S. population, who are already covered by Medicare, Medicaid, employer-based health insurance, Tricare, and Veterans' Health Care. Those who can afford health care and choose not to purchase health insurance will pay a penalty "tax" as part of their yearly filing of Federal Income Tax. The Mandate simply says citizens will either buy health insurance or pay the tax; however, it does not say that failure to buy health insurance is unlawful. This tax will help defray the taxpayers' burden of paying for "freeloader" care or care for those who have chosen not to purchase health insurance. The principle behind the Individual Mandate is that all citizens should be covered by health insurance, so costs are spread over the healthy, those acutely ill, as well as the chronically ill. A second goal is for all citizens to have access to affordable care, in particular, health promotion, wellness, and preventative care. This will ensure severe illnesses are prevented or seen early to prevent complications. As a result, emergency room visits will be decreased as well as prolonged hospital stays and/or frequent readmissions.

The second decision made by the U.S. Supreme Court Justices (7 to 2) deemed the PPACA Medicaid expansion unconstitutionally coercive of states, because it violates Congress' spending clause power being that all existing Medicaid funds would be put at risk for each state, and states were not given adequate notice of voluntarily consent (The Kaiser Family Foundation, 2012a). This decision leaves "Medicaid expansion provision of the PPACA intact and instead restricts the Secretary's (Department of Health and Human Services) enforcement authority" (Kaiser Family Foundation, 2012a, p. 6). Expansion of Medicaid coverage was included in the PPACA to bring more persons at or below 133% of the federal poverty level into statesponsored Medicaid insurance plans. To enable this increased Medicaid enrollment, the Federal Government will pay 100% of costs for states to increase enrollment until 2017, when the Federal Government's share will decrease to 90%. Even with the Federal Government covering costs of care, states would have to cover administrative costs of Medicaid. So this offer still stands in the PPACA, but the Federal Government cannot force states to opt into increased Medicaid coverage. This coverage is estimated to add approximately 16 million enrollees to Medicaid across the 50 states (The Kaiser Family Foundation, 2012b). Coverage increases through 2019 would reduce uninsured adults by 44.5%. While some states (New York, Vermont, Massachusetts) already offer broader Medicaid coverage, other states' Republican governors (Louisiana, Mississippi, South Carolina, and Texas), led by Florida governor Rick Scott, are saying they will opt out of the Medicaid expansion (Pear, 2012). "Gov. Rick Perry (R)…said he does not plan to have Texas participate in the PPACA expansion. The Texas Hospital Association (THA) and its 500 member hospitals plan to build ‘significant' political pressure on state leaders to participate in the expansion, according to THA lobbyist John Hawkins" (The Advisory Board Company, 2012). "Mr. Scott also rejected another provision of the new federal law, saying Florida would not set up a health insurance exchange, or a regulated market where people can shop for coverage" (Pear, 2012).

Responses to the decision of the Supreme Court reflect the deep ideological and political divides in the United States today. We are divided on whether health care is a right or a privilege; we are divided as to who should pay for care. We have states that are cash poor due to the current recession and we have more people out of work, which has increased our numbers of uninsured. Yet, we have the most expensive health care in the world. Costs continue to rise and now are at 17% of our gross domestic product (GDP), yet despite what we pay for care, our health care has poorer outcomes than that offered in other industrialized countries. The World Health Organization ranks the U.S. as #37 in health care.

It is surprising that, although the PPACA offers many benefits that are highly prized, such as removing insurance companies' ability to deny insurance for a preexisting condition in a child (this will be extended to everyone in 2013) or cancel insurance when an annual or lifetime financial cap is met by an individual or family, polls find many who do not think positively about the PPACA. Other benefits include access to prevention and screenings mostly without co-pays. Children can remain on their parents' health insurance until age 26. To control costs, the PPACA specifies that insurance companies cannot use more than 20 cents of each health care premium dollar on overhead and profits (in the past, such companies were spending upwards of 35 cents of every premium dollar on administrative costs). American citizens have been swayed by sound bites and political rhetoric, such as keep "big government" out of health care; we should allow the "free market" an opportunity to work to control health care costs. The PPACA does just this. States and insurance companies are offered the opportunity to design health benefit or insurance exchanges to cover high-risk patients. As was discussed in my last column (Haas, 2012), states have been sitting on the fence waiting for the Supreme Court decision. Now with the decision made, they will be under considerable pressure to establish health insurance exchanges. "At least a third of the states have made little progress setting up new marketplaces, which means either the Federal Government will run their exchanges or they will take part in a state-federal partnership. States face a November 16 deadline to file for federal approval of their health exchanges" (Norman, 2012, p. 2).

Implications for ambulatory care nurses include understanding that coverage for all citizens is essential to providing access to care and ultimately controlling cost and quality of care. Second, knowing what the benefits the PPACA includes and making sure that their organization is offering all the wellness, health promotion, screenings, and prevention options. Many of these primary care activities can be coordinated and done by nurses and advanced practice nurses. Not only will patients benefit, but the PPACA also offers increased reimbursement for providers of primary care services.

Third, nurses need to keep informed as to their state's stance on increased Medicaid coverage for patients and families. They must collaborate with social workers and other professionals to encourage patients to enroll and stay enrolled, as well as understand what benefits are available. The Kaiser Family Foundation has an excellent Web site ( that provides updates on the status of each state regarding Medicaid expansion.

Finally, there will be much rhetoric, as well as many who say they will repeal the PPACA, as we move fully into the presidential election. Legally, a President cannot repeal a law despite the verbiage being used by campaigners today. A President can, however, instruct members of the Cabinet to cease enforcing parts of the law (Browning, 2012). Nurses must be aware that voting down the PPACA requires that an act be substituted that makes provision for equal levels of cost savings. There is no way that we can return to costly care with limited access and quality or business as usual. To date, no alternative health care plan has been offered.

Advisory Board Company, The. (2012). Hospitals prepare state-bystate fight for ACA expansion: States may seek ways to work around gubernatorial opposition. Retrieved from

Browning, W. (2012, June 29). Legal ways to repeal the Affordable Care Act. Retrieved from affordable-care-act-213000309.html

Haas, S.A. (2012). Controversy: Are we being snookered by sound bites? ViewPoint, 34(4), 12-13.

Kaiser Family Foundation, The. (2012a). Focus on health reform: A guide to the Supreme Court's Affordable Care Act decision. Retrieved from

Kaiser Family Foundation, The. (2012b). Kaiser commission on Medicaid and the uninsured. Retrieved from

Norman, J. (2012). Supreme Court upholds health care law in 5-4 decision. Washington Health Policy Week in Review. Retrieved from

Pear, R. (2012, July 2). Republican governor of Florida says state won't expand Medicaid. The New York Times. Retrieved from of-florida-says-state-wont-expand-medicaid.html

Additional Reading
American Nurses Association (ANA). (2012). ANA praises Supreme Court decision upholding Health Care Law: Pres. Daley letter. Retrieved from

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at