As Pandemic Rages, ACA Challenge Threatens Protections for Preexisting Conditions

Olivia Berci, CLS ’22

On November 10th, a week after the presidential election, the Supreme Court heard oral arguments in two consolidated cases challenging the constitutionality of the Affordable Care Act (ACA).[1] Hanging in the balance is not only the insurance tens of millions of Americans gained through the ACA’s premium subsidies (that help enrollees cover their monthly insurance payments) and the law’s expansion of Medicaid,[2] but also the provisions of the law that protect people with preexisting conditions.[3]


Before the ACA, refusing to issue insurance to people with certain health conditions, excluding from coverage care associated with certain illnesses, and charging higher premiums based on a person’s health status were common practices.[4] Fifty-four million Americans have a preexisting condition that would have led to coverage denial in the individual insurance market before the ACA,[5] and that number will likely worsen as coronavirus cases in the United States surge well over 10 million.[6]


COVID-19 will likely become a preexisting condition.[7] In fact, having taken hydroxychloroquine, an anti-malaria drug President Trump pugnaciously promoted as a treatment for the coronavirus,[8] could have impaired one’s access to coverage before the ACA.[9] Should the Supreme Court strike down the ACA, a person who applies for health insurance who is sick or who has been sick with coronavirus could be “turned down, charged more, or offered a plan that excludes coverage for COVID-19 or related symptoms.”[10] Insurers could also cancel coverage if someone develops a health problem linked to an undisclosed coronavirus diagnosis.[11] In other words, an insurer could rescind someone’s policy when they develop an expensive heart or lung condition if they have coronavirus antibodies — even if they were unaware of their exposure to the virus.[12] Analysts further suggest that someone who tests negative for COVID-19 could be discriminated against if insurers determine that those who seek testing carry a higher risk of contracting the virus,[13] which could disincentivize individuals from seeking testing.


To rewind: In 2012, in NFIB v. Sebelius, the Supreme Court narrowly held that it would be unconstitutional for Congress to force Americans to purchase health insurance.[14] But, the Court upheld the ACA’s individual mandate by interpreting the statute as giving people a choice between buying insurance or paying a tax to the IRS.[15] In 2017, Congress zeroed the tax penalty for not purchasing health insurance.[16]  The ACA is still on the books and includes an instruction that people “shall” buy health insurance,[17] but, when Congress eliminated the tax associated with the coverage requirement, the ACA’s instruction became unenforceable: “Neither the Act nor any other law attache[d] negative legal consequences to not buying health insurance, beyond requiring a payment to the IRS.”[18]

Back to present day: The most recent challenge against the ACA was originally brought by a group of 20 attorneys general from Republican states.[19] They claim that the mandate, without the penalty, no longer offers people a choice between complying with the law or facing a tax, and, thus, represents an unconstitutional command to purchase insurance. [20] Moreover, the plaintiffs argue, the entire ACA must be struck because the mandate is inseverable from the rest of the law.[21] Legal scholars argue that neither claim is legally defensible.[22]

A Democratic Congress could revive the ACA by passing a law that cures the constitutional command problem – either by imposing a nominal tax penalty for foregoing insurance or by striking the instruction altogether.[23] However, if Republicans maintain control of the Senate, Senate Majority Leader Mitch McConnell would likely block any attempt by President Biden to restore the law, and, even if Democrats pick up both Georgia Senate seats in the January runoff, Democrats would have to reckon with the Senate’s filibuster.[24]


The ACA may yet survive. Even if the challengers have the votes on the constitutional merits of the challenge, they still have to win the Court over on standing – as a threshold matter – and severability, for the entire law to fall.[25] But, to be clear, the only source of protection for Americans with pre-existing conditions is the ACA.[26] A decision in the case is expected sometime in 2021.[27]

[1] See Transcript of Oral Argument, California v. Texas, 140 S. Ct. 1262 (2020) (No. 19-840), [].

[2] See Chart Book: Accomplishments of Affordable Care Act, Center on Budget and Policy Priorities, [].

[3] See Katie Keith, What It Means To Cover Preexisting Conditions, Health Affairs Blog, [].

[4] See Larry Levitt, Protecting People With Pre-Existing Conditions Isn’t As Easy As It Seems, Kaiser Family Foundation, [].

[5] See Nearly 54 Million Americans Have Pre-Existing Conditions That Would Make Them Uninsurable in the Individual Market without the ACA, Kaiser Family Foundation, [].

[6] See Covid in the U.S.: Latest Map and Case Count, N.Y. Times []; See Keith, supra note 3.

[7] Andy Slavitt & Nicholas Bagley, America’s Health Care Is Under Existential Threat, N.Y. Times, [] (“[C]ontracting the virus is the ultimate pre-existing condition.”).

[8] See Peter Baker et al., Trump’s Aggressive Advocacy of Malaria Drug for Treating Coronavirus Divides Medical Community, N.Y. Times, [].

[9] See Levitt, supra note 4.

[10] Karen Pollitz et al., Is COVID-19 a Pre-Existing Condition? What Could Happen if the ACA is Overturned, Kaiser Family Foundation, [].

[11] See Tara Straw & Aviva Aron-Dine, Commentary: ACA Repeal Even More Dangerous During Pandemic and Economic Crisis, Ctr. on Budget & Pol’y Priorities, [].

[12] Id.

[13] See Pollitz et al., supra note 10.

[14] See National Federation of Independent Businesses v. Sebelius, 567 U.S. 519 (2012).

[15] Id. at 563.

[16] See Heather Long, The final GOP tax bill is complete. Here’s what is in it., Wash. Post.,].

[17] 26 U.S.C. § 5000A(a).

[18] 567 U.S. at 568.

[19] See Texas v. United States, 945 F.3d 355 (5th Cir. 2019).

[20] See, e.g., Brief of Plaintiffs in Support of Application for Preliminary Injunction at 1, Texas v. United States, 945 F.3d 355 (5th Cir. 2019) (No. 18-cv-00167-O).

[21] Id.

[22] See generally Brief for Professors Michael C. Dorf and Martin S. Lederman as Amici Curiae in Support of Petitioners on Question Two, California v. Texas, 140 S Ct. 1262 (2020) (No. 19-840).

[23] See Nicholas Bagley, the Fallout of a SCOTUS Health-Care Decision Could Be Quick, Devastating, and Irreversible, Atlantic, [].

[24] Id.

[25] See Transcript of Oral Argument, California v. Texas, 140 S. Ct. 1262 (2020) (No. 19-840), [].

[26] Some states have moved to ensure the ACA’s protections prohibiting discrimination on the basis of health history are written into state law. See Sabrina Corlette & Emily Curran, Can States Fill the Gap if the Federal Government Overturns Preexisting Condition Protections?, COMMONWEALTH FUND, []. But, before the ACA, state efforts to enact protections for preexisting conditions had destabilizing effects on state insurance markets. See id. (“[S]tate efforts to require insurers to cover people with preexisting conditions resulted in large premium spikes and, in some cases, caused insurers to exit the market.”).

[27] Amy Howe, Argument analysis: ACA seems likely to survive, but on what ground?, SCOTUSblog, [].