December 17, 2018
Federal District Judge Issues Ruling that the Affordable Care Act is Unconstitutional
On Friday December 14, 2018, United States District Judge for the Northern District of Texas, Reed O’Connor, ruled the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) to be unconstitutional after twenty states filed lawsuits in February 2018 arguing that the entire law was invalidated after congress repealed the individual mandate to purchase health insurance. The individual mandate – which was repealed as part of the Tax Cuts and Jobs Act of 2017 – was a central pillar of the health law that required individuals who could afford health coverage to obtain health insurance or face a financial penalty or tax.

In his 55-page decision in Texas v. United States, Judge O’Connor determined that because the Supreme Court’s decision in 2012 ( NFIB v. Sebelius ) to uphold the constitutionality of the ACA was predicated on congress’ exercise of its taxing power, the elimination of the tax renders the entire legislation unconstitutional.

The February 2018 lawsuit was challenged by sixteen other states led by California, arguing that the repeal of the individual mandate did not invalidate the entire law and that the ACA has been instrumental towards extending coverage to millions of Americans.

It is important to note that Judge O’Connor’s ruling did not include an injunction – meaning that the ACA remains the law of the land until further decisions are made by an Appeals Court or the U.S. Supreme Court. Defendants in the lawsuit have vowed to challenge the district judge’s ruling in the Fifth Circuit Court of Appeals – a move that will likely keep the national spotlight on the healthcare law well into the 2020 presidential election cycle.

There are no changes or impacts for individuals who enrolled in the 2019 Health Insurance Marketplace. For American Indians and Alaska Natives (AI/ANs), special protections and provisions such as access to zero cost and limited cost sharing plans, Special Enrollment Periods, and Exemption from Shared Responsibility payments are all still in effect.

It remains unclear how the ruling will impact the future of the Indian Healthcare Improvement Act (IHCIA). While IHCIA was first enacted in 1976, it was permanently reauthorized and attached to the ACA during its passage in 2010. Should the case reach the Supreme Court and be affirmed, it may place IHCIA in legal jeopardy. Additionally, the law’s provisions around Medicaid expansion – which contributed to roughly 300,000 AI/ANs obtaining health coverage – could also face a precarious legal position. Although the Supreme Court ruled Medicaid expansion to be voluntary decisions by individual states in a previous decision, the ACA made significant changes to how Medicaid operates.

Both the ACA and the permanent reauthorization of IHCIA made significant changes to the entire Indian health system, and its preservation has been a top priority for many Tribal Nations. 

The National Indian Health Board (NIHB) remains deeply engaged on this issue and will be closely monitoring its status as the district judge’s ruling is brought before a higher court. Should you have any questions about the ruling, please contact NIHB Director of Policy, Devin Delrow, at or NIHB Deputy Director and Director of Public Health Policy and Programs, Carolyn Angus-Hornbuckle, at .