Tag Archives: APA

The ACA Twilight Zone

Death by a thousand cuts has been the Trump Administration’s approach to the Affordable Care Act (ACA).  To be sure, President Trump  tweeted on April 23, 2017 that “ObamaCare is in serious trouble.”  On October 13, 2017, he tweeted, “ObamaCare is a broken mess. Piece by piece we will now begin the process of giving America the great HealthCare it deserves!”  On May 30, 2018, he stated: “For the most part, we will have gotten rid of a majority of Obamacare.”  And on June 4, 2018, he tweeted, “We had Repeal & Replace done (and the saving to our country of one trillion dollars) except for one person, but it is getting done anyway. Individual Mandate is gone and great, less expensive plans will be announced this month.”

In the courts, the ACA has certainly been no stranger to the artful attack.  But two lawsuits, one filed in Texas and the other in Maryland, have gained nationwide traction and hold nationwide consequences.  The first suit, Texas v. US, made its way to U.S. District Court Judge Reed O’Connor’s bench in the Northern District of Texas.  The 20-state GOP led suit was filed on February 26, 2018 by Texas Attorney General Ken Paxton.  It argues that since the ACA was only upheld by the Supreme Court in NFIB v. Sebelius because the individual mandate was a tax, and now that the Tax Cut and Jobs Act of 2017 (TCJA) zeroed-out the individual mandate penalty, the entire ACA is unconstitutional.  The Plaintiff-states also argue that since the ACA does not have a severability clause – a clause that would allow the rest of the statute to live if one part is stricken – the ACA as a whole must fall.

Under Attorney General Jeff Sessions direction, the government will not defend the ACA’s constitutionality.  Defending the ACA, and its patient protections like the prohibition on insurers from discriminating against patients with pre-existing conditions, are 17 Democratic attorneys general representing their respective states as Intervenor-Defendants.  A slew of patient groups and scholars filed amicus briefs in support of the Intervenor-Defendants, but only Citizens United filed as amicus in favor of the Plaintiff-States.  The American Cancer Society Cancer Action Network filed as amicus, urging the court to uphold the ACA and to “recognize Congress’s clear intent to improve access to lifesaving health care for millions of Americans.”  A bipartisan group of law professors filed as amicus, arguing that “[t]he arguments of both the plaintiff States and the United States on the severability of the insurance mandate from the other provisions of the ACA are inconsistent with settled law.”  On July 19, 2018, Senate Democrats introduced a Senate resolution that would authorize Senate Legal Counsel to intervene in Texas v. US to defend the ACA’s patient protections for people with pre-existing conditions.

The second suit, City of Columbus v. Trump, filed on August 2, 2018 by the Cities of Baltimore, Chicago, Columbus, and Cincinnati in the U.S. District Court for the District of Maryland alleges that the Trump Administration’s actions over the last several years amount to an unconstitutional sabotage of the law the President is required to faithfully execute.  The suit makes two claims: the first claim that the Administration is acting arbitrarily and capriciously, and the second that President Trump is violating the “Take Care” Clause of the Constitution.  Under the Take Care Clause of the U.S. Constitution, the President and his or her Administration must “take care that the laws be faithfully executed.” U.S. Const. art. II, § 3.  The suit cites a range of administrative actions taken to sabotage the ACA and have the aim and effect of weakening ACA exchanges, driving up premiums, and driving out issuers, ultimately increasing the rate of the uninsured and underinsured.

Judge O’Connor, after first announcing that oral arguments in Texas v. US would take place on Monday, September 10, moved up oral arguments to Wednesday, September 5, at 9:30 a.m.  At the same time in Washington, D.C., Supreme Court nominee Brett Kavanaugh will be testifying before the Senate Judiciary Committee for potential confirmation.  As some have noted, the fate of the ACA could turn on Kavanaugh’s appointment to the Supreme Court.  Kavanaugh’s preeminent views on separation of powers and his textualist-meets-originalist approach to statutory interpretation is consistent and can be expected to appear in his opinions, but is alarming to health care advocates and patients.  Kavanaugh’s jurisprudence shows that he cares deeply about administrative law and is unlikely to “deconstruct the administrative state,” but he is likely to “put a tighter leash on the regulatory state.”  In all, the fate of the ACA remains to be seen.

 

 

 

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Forcibly Medicating Mentally Ill Death Row Inmates

First year law students are taught the basic theories of punishment in their Criminal Law classes within the first week — deterrence, rehabilitation, isolation, education, and retribution.  These relatively straightforward concepts seem simple enough until they are complicated by obstacles that exist solely outside of textbooks and in the real world like mental illness and the death penalty.

On September 11, 2013, the Texas Court of Criminal Appeals held that a court may not order the forcible medication of a mentally ill death row inmate to render him competent to be executed.  (see Staley v. Texas ; Chattanooga Times Free Press; Death Penalty Information Center)  This decision is one of a number of cases across the country, including state supreme courts in Louisiana and South Carolina, that have had the same essential ruling — that an inmate on death row cannot be forcibly medicated to stand trial or be executed.  (Star-Telegram)

In the cases dealing with forcibly medicating mentally ill death row inmates, the court is faced with the task of considering a host of difficult questions in addition to keeping the delicate balance, including issues of public health, policy, state law, and the specific facts of each case.  Still, regardless of the appreciation for the challenge of the task at hand, many critics of decisions such as the one that the Texas court handed down believe that the American court system is not a strong enough institution because of its apparent inability to protect the collective security of the public.  Those in favor the decision believe that the court intelligently practiced judicial restraint in remaining faithful to the text of the state’s constitution.   (John Katz, PC; Penn State Law Review)

Interestingly, both the American Psychiatric Association (APA) and American Medical Association (AMA) have publicly denounced the practice of forcible medication, calling it ethically unacceptable.  (see http://www.medscape.com/viewarticle/747795)  The APA is specifically concerned that when a court is making life-altering decisions and writing about psychiatric illness and treatments, judges have an accurate set of facts to work from.  Furthermore, the APA is concerned that that the authorities who have custody of a defendant to make decisions regarding forcible medication can do so in a timely and efficient manner.  (Death Penalty Information Center)

Considering the gravity of any decision involving forcible medication and the potential it has for serious health law and policy consequences, it is surely an issue that will be highly scrutinized and debated for years to come.

 

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