5 Challenges the Affordable Care Act Overcame in the Last 15 Years

As the Affordable Care Act (ACA) marked its 15th anniversary this year, Justices on the Supreme Court continue to deliberate over the fate of its preventive services mandate under the Appointments Clause.¹ The ongoing Kennedy v Braidwood Management case centers on whether the US Preventive Services Task Force (USPSTF), which recommends services insurers must cover, wields authority that requires its members to be appointed by the President and confirmed by the Senate.

Earlier this week, the Court heard oral arguments, with Justices debating whether USPSTF members are “principal officers” and whether the body operates independently of HHS, with pivotal Justices like Amy Coney Barrett and Brett Kavanaugh pressing both sides. If the Court sides with Braidwood, insurers could drop coverage for over 30 key preventive services, including those related to HIV, cancer, and mental health.

While a decision from the Supreme Court is anticipated in June or July of this summer, when the current term ends, The American Journal of Managed Care^® reflects on 5 challenges the ACA has overcome in its 15 years.

1. NFIB v Sebelius

In a narrow 5-4 decision, the Supreme Court upheld the ACA, ruling that the individual mandate's penalty for not purchasing insurance is constitutional when viewed as a tax, although not under the Commerce Clause.² Chief Justice John Roberts, casting the decisive vote, emphasized that judging the policy's "wisdom" is not the Court's role.

The Court also ruled that the ACA's Medicaid expansion was unconstitutionally coercive, as it threatened states with the loss of existing funding if they refused to comply; however, it found this provision severable, thereby preserving the rest of the law. As a result, key ACA protections remain in place, including coverage for preexisting conditions, extended parental insurance for young adults, and equal treatment for gender in insurance pricing.

2. King v Burwell

In the 2015 King v Burwell case, the Supreme Court ruled to uphold federal health insurance subsidies provided through the ACA.³ This case challenged the legality of the subsidies offered in the 34 states where the federal government, rather than individual states, operated ACA Marketplaces. If the Court had ruled in favor of the challengers, millions of low- and middle-income individuals in those states would have lost access to premium tax credits, which would have resulted in significant increases in health insurance premiums for those affected.

This situation could have led to healthier individuals exiting the insurance market, thereby destabilizing risk pools and driving premiums even higher in future years. A KFF report provided detailed, state-by-state data, including the number of people receiving subsidies as of March 31, 2015, the total federal dollars distributed in subsidies, the average subsidy per enrollee, and the estimated increase in premiums if subsidies were disallowed. These projections highlighted the potentially severe economic and coverage-related consequences of removing the ACA’s subsidy structure in states utilizing the federal marketplace.

3. Better Care Reconciliation Act of 2017

The Better Care Reconciliation Act (BCRA) was introduced in June 2017 in the Senate as a comprehensive repeal-and-replace bill, following the House's American Health Care Act.⁴ Key features of the BCRA included the phasing out of Medicaid expansion starting in 2020, reductions in federal funding for Medicaid overall, and the repeal of the ACA's individual mandate.

Additionally, the bill would have allowed states to waive essential health benefit requirements while maintaining some ACA taxes for a limited period. However, when 9 Republicans stated they would not vote for the bill, indicating it lacked support in the Senate, the final vote was cancelled. This prompted Senate Majority Leader Mitch McConnell (R, Kentucky) to return to the previous plan: repeal and delay.

4. Health Care Freedom Act of 2017

Shortly following the cancellation of the BRCA, the Senate narrowly rejected the Republican “skinny repeal” of the ACA after a dramatic late-night 49–51 vote.⁵ Thought to be the best chance of appeasing moderates and advancing to a conference with the House of Representatives, the skinny repeal bill was a pared-down version of past efforts to repeal and replace the ACA. The bill got rid of some provisions of the ACA, like the individual mandate and fines, but largely left the ACA intact.

The vote was blocked with the support of the Republican senators Susan Collins (Maine), Lisa Murkowski (Alaska), and John McCain (Arizona), who voted against the measure. McCain’s surprise vote was pivotal and came after expressing frustration with the secretive, rushed process behind the bill, which sought to eliminate the individual mandate but offered no meaningful replacement. His stance called for a return to bipartisan efforts to improve the health care system, and his vote dealt a major setback to Republican efforts to repeal the ACA.

5. California v Texas

In a 7-2 ruling, the Supreme Court upheld the ACA, marking the third time the law survived a constitutional challenge since it was signed in 2010.⁶ According to the Court, the plaintiffs in California v Texas lacked standing to challenge the law’s individual mandate after its penalty was reduced to $0. Judges appointed by President Donald Trump split their votes, with Justices Brett Kavanaugh and Amy Coney Barrett voting with the majority, while Justice Neil Gorsuch was in dissent, signing on to an opinion from Justice Samuel Alito.

The decision preserved key provisions such as Medicaid expansion, protections for those with preexisting conditions, no-cost preventive services, and support for value-based care initiatives. The ruling affirmed the ACA's role in expanding health care access, which has helped reduce the uninsured rate and now provides coverage for over 31 million Americans.

References

1. Bonavitacola J. Supreme Court hears oral arguments in Braidwood case. AJMC^®. April 22, 2025. Accessed April 24, 2025. https://www.ajmc.com/view/supreme-court-hears-oral-arguments-in-braidwood-case

2. National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012). Justia.com. Accessed April 25, 2025. https://supreme.justia.com/cases/federal/us/567/519/

3. State-by-state effects of a ruling for the challengers in King v. Burwell. KFF.org. June 2, 2015. Accessed April 25, 2025. https://www.kff.org/interactive/king-v-burwell-effects/

4. Joszt L. Without votes for BCRA, McConnell calls for repeal and delay of ACA. AJMC. July 18, 2017. Accessed April 25, 2025. https://www.ajmc.com/view/without-votes-for-bcra-mcconnell-calls-for-repeal-and-delay-of-aca

5. Joszt L. Senate rejects skinny repeal; 3 Republicans vote no. AJMC. July 28, 2017. Accessed April 25, 2025. https://www.ajmc.com/view/senate-rejects-skinny-repeal-3-republicans-vote-no

6. Inserro A, Mattina C. Supreme Court tosses challenge to ACA for lack of standing. AJMC. June 17, 2021. Accessed April 15, 2025. https://www.ajmc.com/view/supreme-court-tosses-challenge-to-aca-for-lack-of-standing