Amicus Brief: National Hospital Associations in Support of the California State Coalition and House of Representatives

The AHA, joined by America’s Essential Hospitals, Association of American Medical Colleges, and Federation of American Hospitals today urged the Supreme Court to reverse a federal appeals court decision that held the Affordable Care Act's individual mandate unconstitutional.

Statement of Interest1

The American Hospital Association (“AHA”) represents nearly 5,000 hospitals, health systems, and other health care organizations, plus 43,000 health care leaders who belong to its professional membership groups. AHA members are committed to improving the health of communities they serve and to helping ensure that care is available to and affordable for all Americans. AHA educates its members on health care issues and advocates to ensure that their perspectives are considered in formulating health policy.

America’s Essential Hospitals is the national association representing more than 325 hospitals and health systems that provide a disproportionate share of the nation’s uncompensated care and are dedicated to providing high-quality care for all, including underserved and low-income populations. Filling a safety-net role in their communities, its member hospitals offer a full range of services to meet community needs, including specialized services that would otherwise be unavailable (for example, trauma centers, emergency psychiatric facilities, and burn care), public health services, mental health services, substance abuse services, specialty care services, and wraparound services such as transportation and translation to ensure that patients can access the care being offered. Many also provide training for physicians and other health care professionals.

The Association of American Medical Colleges (“AAMC”) is a not-for-profit association representing all 155 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems; and more than 80 academic and scientific societies. Through these institutions and organizations, the AAMC serves the leaders of America’s medical schools and teaching hospitals and their more than 173,000 faculty members, 89,000 medical students, 129,000 resident physicians, and more than 60,000 graduate students and postdoctoral researchers in the biomedical sciences.

The Federation of American Hospitals (FAH) is the national representative for over 1,000 leading taxpaying hospitals and health systems throughout the United States. FAH members provide patients and communities with access to high-quality, affordable care in both urban and rural America. Our members include teaching and non-teaching, acute, inpatient rehabilitation, behavioral health, and long-term care hospitals and provide a wide range of inpatient, ambulatory, post-acute, emergency, children’s, and cancer services. Dedicated to a market-based philosophy, the Federation provides representation and advocacy on behalf of its members to Congress, the Executive Branch, the judiciary, media, academia, accrediting organizations, and the public.

Amici’s members are deeply affected by the Nation’s health care laws, particularly the Affordable Care Act (“ACA”). See Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010); Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029. That is why they have filed briefs in support of the law in this Court and in lower courts across the Nation. Amici write to offer guidance, from hospitals’ perspectives, on the legal issue in this case and the harmful impact that a ruling striking down the ACA will have on the American health care system and all who depend on it to keep them well and to care for them when they are ill.

Summary of Argument

Since its enactment in 2010, the ACA has made substantial progress toward improving Americans’ access to quality health care. More Americans have health insurance coverage because of the ACA’s many reforms, such as Medicaid expansion, the guaranteed-issue requirements, premium subsidies, and the creation of state insurance exchanges. And the ACA’s wide range of programs that encourage innovation in patient care have led to improvements in the quality of American health care.

Congress recognized this progress when it amended the ACA in 2017. Understanding that the ACA’s health-insurance-coverage gains can be traced back to multiple provisions of the law, and that the ACA’s individual mandate had contributed less to the growth than originally expected, Congress decided that the mandate no longer needed to be enforced for the ACA’s reforms to continue. And so the mandate was eliminated, but the ACA’s many other provisions were left undisturbed.

Despite this, the Fifth Circuit below declared the mandate invalid and avoided the severability issue entirely, instead remanding for the district court to “provide additional analysis” of the ACA’s provisions. Pet. App. 3a–4a.2 It did so even though the question of severability turns on the interpretation of the text and history of the ACA, the kind of question that appellate courts have “no difficulty” answering without guidance from district courts. Buckley v. Valeo, 424 U.S. 1, 108 (1976) (per curiam); see also Murphy v. National Collegiate Athletic Ass’n, 138 S. Ct. 1461, 1482 (2018).

Law, logic, and experience all counsel in favor of severing the individual mandate. As for the law, the evidence shows the ACA can “function[] independently” of the mandate. Alaska Airlines, Inc. v. Brock, 480 U.S. 678, 684 (1987). The evidence before Congress in 2017 showed that repealing the mandate and eliminating the penalty would have roughly the same effect on coverage as eliminating just the penalty, and that the ACA would continue to function without either. As for the logic, Congress in 2017 considered several options for amending the ACA, ranging from a complete repeal to the elimination of the mandate penalty. Congress chose the option that least disturbed the ACA’s reforms, a decision incompatible with the district court’s conclusion that Congress preferred no ACA to one without the mandate. And as for experience, the available evidence, including marketplace enrollment numbers, shows that Congress was correct to conclude that the ACA can function without the individual mandate.

The likely catastrophic effects of a ruling invalidating the ACA confirm that Congress did not intend that result. Judicial repeal would threaten improvements made to the care Americans receive by eliminating innovations, including programs designed to combat substance abuse. It would also roll back coverage gains, leaving many newly insured patients without access to everything from routine checkups and tests to treatment for chronic illnesses and opioid addiction. The increase in uninsured patients would also strain the resources of hospitals, particularly those that serve low-income and rural populations. And it would do so at a time when a global pandemic is already straining hospitals’ ability to provide care at precisely the time when Americans need it the most.

The court of appeals’ decision should be reversed.


  1. No party or counsel for a party authored this brief in whole or in part. No party, counsel for a party, or person other than amici curiae, their members, or counsel made any monetary contribution intended to fund the preparation or submission of this brief. All parties have consented to the filing of this brief.
  2. Citations to “Pet. App.” are to the petition appendix in California v. Texas, No. 19-840.

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