Last year, 40% of  Americans polled did not know that the ACA, aka Obamacare, formerly Healthcare Reform, was the law of the land. Congress did enact it in 2010, but it was controversial from the start, barely survived thefirst Supreme Court ruling (5-4 to uphold its constitutionality), and remains a target of lawsuits and court rulings that threaten to eviscerate it. Maybe the 40% public was not so much ignorant as prescient, for the Supreme Court has continued to take cases that challenge various aspects of the law, and sometimes has disallowed its key elements.

The ACA was passed by Congress to help people of moderate means, especially the young and the poor, to get access to health insurance. In a national “system” based on employer contributions to private health insurers, millions of Americans had been left out. Those millions were going to be welcomed into the system, mainly by means of the ACA’s two big innovations: state-based “insurance exchanges” and federally-funded expansion of Medicaid in the states. The latter was shot down as a requirement by the Supreme Court in 2012; the former is facing possible execution in the same arena.

In an unprecedented and historic failure to comply with federal law, more than half the states refused to implement the Medicaid expansion, a position that was upheld in a Supreme Court 7-2 ruling. The vulnerability of the ACA was further underscored in the recent Supreme Court ruling on the Hobby Lobby case, in which employers, citing personal religious beliefs, were affirmed in their right to deny aspects of ACA-mandated reproductive healthcare to female employees.

Now, the ACA is threatened in another of its key provisions: the health insurance exchanges that are mandated for each state. These exchanges, signature elements of the ACA, are the marketplaces for insurance options that supplement the offerings of private insurers. Thirty-six states did not set up an exchange by the Jan. 1st deadline, which, under the ACA, automatically makes the federal Department of Health & Human Services (HHS) the operator of the exchange in that state. A challenge to the HHS role in federal court may make its way to the Supreme Court for a final ruling on the validity of the exchanges. If the judges take the case and rule as they did with Medicaid expansions, then the ACA, stripped of its two most important provisions, would fall to the ground as an effective federal law.

Clinical social workers, have you felt the impact of the ACA on your practice?aca poll

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