Procedure. Who are the parties? Who brought the action? In what court did the case originate? Who won at the trial-court level? What is the appellate history of the case?

Facts. What are the relevant facts as recited by this court? Are there any facts that you would like to know but that are not revealed in the opinion?

Issues. What are the precise issues being litigated, as stated by the court? Do you agree with the way the court has framed those issues?

Holding. What is the court's precise holding (decision)? What is its rationale for that decision? Do you agree with that rationale?

Implications. What does the case mean for healthcare today? What were its implications when the decision was announced? How should healthcare administrators prepare to deal with these implications? What would be different today if the case had been decided differently?

The Court Decides Chapter 2: Access to Healthcare Insurance and Treatment 93 ring v. Burwell 576 U.5. 473 (2015) Roberts, Chief Justice credits-reduced the uninsured rate in Mas establish and operate such Exchange within chusetts to 2-6 percent, by far the lowest the State." or charge a higher premium because in the Nation. [Massachusetts's reforms- The issue in this case is whether the preexisting conditions. Then the opini sometimes referred to as "Romneycare, " a Act's tax credits are available in States that continues. 1 . .. reference to then governor Mitt Romney- have a Federal Exchange rather than a State The guaranteed issue and community were a model for drafters of the ACA] Exchange. The Act initially provides that Lax ing requirements achieved [ the goal of ! credits "shall be allowed" for any "applicable Hopedaroundcarnage in the indi. ng insurance available to all, but they taxpayer," 26 U.S.C. 5 368, The Act then mid bach Estate market First, the Act provides that the amount of the tax credit has isvery Los Dating a prison's health It amount when deciding a better to sell an unintended consequence: They ended [The opinion next describes the ACA's reform provisions: (1) adoption of the guaranteed depends in part on whether the taxpayer has aged people to wait until they got sick to issue and communily rating requirements; enrolled in an insurance plan through "an Exchange established by the State" (under 5 Around the Ad prana ly requires each per insurance. Why buy insurance coverage (2) a requirement for individuals to have you are healthy, if you can buy the same insurance or make a tax payment to the 18031 of the ACAL. towsonstate coverage or make erage for the same price when you beck RS-the "individual mandate" upheld in I To implement these provisions, the NFIB v. Sebelius, and () the giving of tax 185 promulgated a rule that mode tax And Fit the At gives tax credits to certain ill? This consequence- known as "adverse selection" -led to a second: Insurers way credits to low income persons to help make credits available to applicable taxpayers people to mate isagoor more affordable. insurance more affordable.). . . . who enrolled in an insurance plan through forced to increase premiums to account These three reforms are closely inter- an exchange regardless of whether the nowhas the common afan "Exchange " in the fact that, more and more, it was the sig twined. . . . Congress found that the guar- exchange was established by the state or not Sure-butically a markriplace that rather than the healthy who were buying anteed issue and community rating require- by HHS. The petitioners in this case were insurance. And that consequence fed back ments would not work without the coverage four residents of Virginia who do not want allows people to compare and purchase hercarer point The And gives each State the requirement. And the coverage requirement to buy health insurance. They argue that would not work without the tax credits. The eppodanby do establish its our Exchange. into the first: As the cost of insurance rose Virginia's exchange does not qualify as "an bout provides that the Federal Government will even more people waited until they berang ill to buy it. reason is that, without the tax credits, the Exchange established by the State" because cost of buying insurance would exceed eight establish the Exchange if the State does not. it was established by HHS, that they there- percent of income for a large number of fore should not receive tax credits, and that Thes case is about whether the Act's This led to an economic "death spiral" As premiums rose higher and higher, and individuals, which would exempt them from they are exempt from the individual mandate the coverage requirement. [The ACA exempts because without the credits the cost would State no mater who establishes the State's the number of people buying insurance say Exchange. Specifically, the question pre. lower and lower, insurers began to leave from the individual mandate individuals who be more than 8 percent of their income. ]. . .. sented is whether the Act's tax credits the market entirely. As a result, the rum. would have to spend more than 8 percent of ber of people without insurance increased their income on health insurance.] 1I are available in States that have a Federal dramatically. Petitioners argue that a Federal Exchange In 1996, Massachusetts adopted the goes In addition to those three reforms, the Act is not "an Exchange established by the State anteed issue and community rating require requires the creation of an "Exchange" in under [42 U.S.C. 518031]," and that the IRS Here the chief justice summarizes what he ments and experienced similar results. But each State where people can shop for insur- [regulation making tax credits available to rails a They hittry of fled health insur n 2006, Massachusetts added two more ance, usually online. An Exchange may be federal exchange enrollees] therefore contra- awe rejon, "Including too related concepts reforms: The Commonwealth required ind created in one of two ways. First, the Act dicts Section 368. The Government responds oder several states adopted in the 19gos: a viduals to buy insurance or pay a penalty, and provides that "[elach State shall . . . estab- that the IRS Rule [referred to earlier] is lawful "powanted issue " requirement and a "com- lish an American Health Benefit Exchange it gave tax credits to certain individuals to because the phrase "an Exchange estab- mundyality " requirement. Together, these . . for the State." Second, if a State none- gbrow sen that agone who wanted ensure that they could afford the insurance lished by the State under [42 U.S.C. 518031]" theless chooses not to establish its own health insurance in those states could buy they were required to buy. The combination should be read to include Federal Exchanges Exchange, the Act provides that the Secre- . . . It is . . . our task to determine the cor- it and insures could not deny coverage of these three reforms- insurance market tary of Health and Human Services "shall . .. rect reading of Section 368 . . . [and in doing regulations, a coverage mandate, and tax (continuCORO The lam of braincare Administration established under section 18031." we import that definition into Section at Chapter a: Access to Healthcare Insurance and Treatment 95 we must mad the uges in their contest Act tells the Secretary to "establish ,4 ate such 'American Health Benefit Ed established under section 18031," statutory scheme . . . because only one of requirement- would not apply In a meaning- Money at raider Sipvote Count casel suggests that Section 18041 authorizein Secretary to establish an Exchange und Section 18031, not (or not only) under s the permissible meanings produces a sub ful wary 18041. Otherwise, the Federal Exchange stantive effect that is compatible with the . .. The combination of no tax credits and rest of the law," Here, the statutory scheme an ineffective coverage requirement could definition, would not be an "Exchange" compels us to reject petitioners' interpreta well push a State's Individual Insurance mar. This interpretation of "under [42 4.5. tion because it would destabilize the indi- sel into a death spiral. . .. 518031]" fits best with the statutory come vidual insurance market in any State with a it is implausible that Congress meant the mpower peethsuch in Lachance All of the requirements that an Exchange Federal Exchange, and likely create the very Act to operate in this manner. .. . Congress "death spirals" that Congress designed the made the guaranteed issue and community Allparties agree that a Federal Exchange must meet are in Section 18031, So it is so sible to regard all Exchanges as establish Act to avoid. . . . rating requirements applicable in every State The guaranteed issue and community rat- in the Nation. But those requirements only Bullies a "on Exchanger " Ise purposes of under that provision. In addition,... the ing requirements ensure that anyone can buy work when combined with the coverage repeatedly uses the phrase "established Insurance: the coverage requirement creates requirement and the tax credits. 50 It stands tion pick Section 18031 provides that an incentive for people to do so before they to reason that Congress meant for those pro- Touch State shal. . . establish an Ameri. under [42 U.5.C. 518031)" in situations where it would make no sense to distingling get sick; and the tax credits-it is hoped- visions to apply in every State as well. . .. can Make Bestie Exchange.. . for the Some ".. /Bad) in the State chooses not to down, Section 18043 provides that the Sec- between State and Federal Exchanges, A key make insurance more affordable. Together. those reforms "minimize . . . adverse selec- tion and broaden the health insurance risk Congress passed the Affordable Care Act retary 'stall, . . establish and operate such eral Exchange may therefore be considered one established "under [42 U. S. C. 51Berg, pool to include healthy individuals, which to improve health insurance markets, not Eachorgy with the State " ... The Affordable Care Act contains Boy will lower health insurance premiums." 42 to destroy them. If at all possible, we must Byusing the phrase "such Exchange, than a few examples of inartful drafting.. U.5.C. 5 18091(2)0). interpret the Act in a way that is consistent Section 18cua instructs the Secretary to with the former, and avoids the latter. Section extadlish and operate the same Exchange Wje "must do our best, bearing in mind the Under petitioners* [interpretation]. how- fundamental canon of statutory construction ever, the Act would operate quite differ- 368 can fairly be read consistent with what that the State was directed to establish ently in a State with a Federal Exchange. ander Section 18031. . . . An other words, that the words of a statute must be read in we see as Congress's plan, and that Is the As they see it, one of the Act's three major reading we adopt. their context and with a view to their place in reforms- the tax credits-would not apply. The judgment of the United States Court of State Exchanges and Federal Exchanges are equivalent - they must meet the same the overall statutory scheme" [citing a 284 And a second major reform- the coverage Appeals for the Fourth Circuit is Affirmed. requirements, perform the same fund- case). After reading Section 36B along with does, and serve the same purposes. other related provisions in the Act, we can Discussion Questions Although State and Federal Exchanges not conclude that the phrase "an Exchange established by the State under [Section 1. As discussed in chapter 1, when interpreting a statute, judges typically analyze not only are established by diferent sovereigns, 18031)" is unambiguous. the text of the law itself but also its history and purpose, other judicial decisions, and Sections 18031 and 18041 do not suggest the consequences of one outcome versus another. Compare the majority opinion in King fat they differ in any meaningful way. A v. Burwell with Justice Scalia's dissent as summarized in the text. In your opinion, which Federal Exchange therefore counts as "an B rationale addresses those factors more satisfactorily? change" under Section 366. Given that the text is ambiguous, we must 2. Can you explain the logic behind the majority opinion? Do you find it persuasive? turn to the broader structure of the Act to 3. What are the "death spirals" to which the chief justice refers? determine the meaning of Section 368. "A Act defines the term "Exchange" to an American Health Benefit Exchange provision that may seem ambiguous in iscle tion is often clarified by the remainder of the