Amicus Brief: 36 State Hospital Associations in Support of Petitioners

May 13, 2020

In a friend-of-the-court brief, 36 state hospital associations urged the Supreme Court to reverse a federal appeals court decision that held the Affordable Care Act's individual mandate unconstitutional

Interest of Amici Curiae

This brief1 is filed on behalf of 36 state hospital associations,2 which represent over 5,000 hospitals and health systems that treat tens of millions of patients every year and currently stand on the frontlines of a global pandemic. Amici and their members (hereafter “amici”) share an interest in delivering quality, affordable health care, and therefore in the preservation of the Patient Protection and Affordable Care Act (ACA). Since enactment of the ACA, amici have spent substantial resources embracing the law’s reforms that have resulted in the delivery of higherquality, more coordinated care at a lower cost. Amici are submitting this brief because they support the ACA and because reverting back to old delivery models would significantly disrupt amici’s operations and patient care.

Although this brief focuses on the delivery of health care services in this country, amici endorse the constitutional and severability arguments presented by petitioners, which demonstrate that the Fifth Circuit wrongly decided this appeal.3 Amici agree with petitioners that the ACA’s minimum coverage provision, as amended, is constitutional. But if this Court decides otherwise, amici concur that this Court should hold that the rest of the ACA must remain intact. As petitioners have demonstrated, it is clear that the 2017 Congress would have intended that the ACA remain in force if the minimum coverage provision were judicially invalidated. After all, the 2017 Congress thought it was legislatively invalidating that provision when it zeroed out the tax for noncompliance. Having observed the ACA work for years—including in hospitals and health systems across the country—the 2017 Congress had expressly rejected legislation that would have repealed the entire ACA which definitively demonstrates its intent that the remaining provisions are severable from the minimum coverage provision.


The Patient Protection and Affordable Care Act4 made health care available to millions of individuals through insurance subsidies and expansion of the federal Medicaid program. Often overlooked in the controversy regarding those provisions, which occupied just two of ten titles and fewer than 300 pages of the 974-page bill, are the ACA’s many other basic health care reforms. These include, for example, amendments to the Indian Health Care Improvement Act, a pathway for approval of generic biologics by the Food and Drug Administration, provisions making Medicare Part D prescription drugs more affordable, the addition of nutritional information to restaurant menus, disclosure of drug company gifts to physicians, and the subject of this brief: foundational changes to the way health care services are delivered and paid for.

The ACA’s “delivery reforms,” which the Fifth Circuit and the district court did not even mention in their opinions, transformed the way hospitals and health systems deliver and are paid for health care. These provisions have promoted innovative, new models of care and have provided substantial investments in the health care workforce. They also addressed prevention and launched new initiatives to improve health care quality. In the ten years since the ACA was enacted, these reforms have made fundamental improvements in the quality and coordination of care, saving billions of federal dollars. They have become integral to the delivery of health care services in the United States.


In their attempt to strike down every provision of the ACA, respondents have characterized the Act’s major health care delivery reforms as “minor” provisions. This misnomer led the district court to invalidate these important provisions along with the rest of the law because the court considered them “adjuncts of” the requirement that most Americans obtain health insurance coverage or pay a penalty (the “minimum coverage provision”). The Fifth Circuit, to its credit, recognized that the district court’s severability analysis was superficial and ordered the district court to conduct the severability analysis with a “finer-toothed comb.” Nevertheless, the Fifth Circuit adopted the district court’s faulty taxonomy, labeling scores of critical provisions as “minor” and abdicating its responsibility to rule on the purely legal severability issue. Both courts failed to recognize that the ACA’s delivery reforms have transformed the delivery of health care in the United States by providing more integrated, cost-effective care, while maintaining quality. And because there is no basis for concluding that Congress intended those provisions—which were enacted in separate titles and function independently of the ACA’s insurance-related provisions—to be inseverable, they, along with the other remaining provisions, should be left intact regardless of how the Court rules on the constitutionality of the minimum coverage provision.

  1. Pursuant to Rule 37, all parties have provided written consent to the filing of this amici curiae brief. No counsel for a party authored this brief in whole or in part, and no counsel or party made a monetary contribution intended to fund the preparation or submission of this brief. No person other than amici curiae, their members, or their counsel made a monetary contribution to its preparation or submission.
  2. The individual associations are described in the Appendix to this brief.
  3. See Pet’r States Br. 25–48; U.S. House of Representatives Br. 14–19, 34–50.
  4. Pub. L. 111-148, 124 Stat. 119 (2010). All citations to the law are styled as ACA § ___.