# Amicus Curiae Brief — King v. Burwell, 135 S. Ct. 475 (2014) (No. 14-114) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40385016_0338%3A40 ## Record - **Collection:** Supreme Court brief - **Document type:** Amicus Curiae Brief - **Published:** January 1, 2014 ## Text Supreme Court, U.S. FILED JAN 28 2015 No. 14-114 OFFICE OF THE CLERK IN THE Supreme Court of the United States DAVID KING, et al., Petitioners, Vv. SYLVIA MATHEWS BURWELL, AS UNITED STATES SECRETARY OF HEALTH AND HUMAN SERVICES, et al., Respondents. ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT BRIEF OF AMICI CURIAE HARVARD LAW SCHOOL CENTER FOR HEALTH LAW AND POLICY INNOVATION, ET AL. IN SUPPORT OF RESPONDENTS MARK C. FLEMING Counsel of Record RICHARD A. JOHNSTON RACHEL L. GARGIULO WILMER CUTLER PICKERING HALE AND DORR LLP 60 State Street Boston, MA 02109 (617) 526-6000 mark.fleming@wilmerhale.com TABLE OF AUTHORITIES INTEREST OF AMICI CURIAE SUMMARY OF ARGUMENT ARGUMENT TABLE OF CONTENTS REVERSAL OF THE JUDGMENT BELOW WOULD DEPRIVE MILLIONS OF RE- CENTLY INSURED AMERICANS OF NEW- FOUND AcCESS TO HEALTH INSUR- ANCE, SERIOUSLY THREATEN HEALTH OUTCOMES, AND UNDERMINE THE NA- TION’S ABILITY TO ADDRESS EPIDEM- IcS AND OTHER PUBLIC HEALTH yea RSE Aer Nene to cee Ee RO 5 A. The ACA’s Provision Of Federal Subsidies In All States Has Dra- matically Improved Health Insur- ance Access And Is Integral To The Act’s Insurance Market Reforms ¥ The ACA’s subsidies have yielded unprecedented gains in insurance access among middle- and low-income households .............. The subsidies are integral to maintaining insurance market reforms for all exchange par- Insurance access gains and market reforms in most States would be lost if the decision below 18 TE VETSCM ........cccccccccccccescesecees (i) SHES HK OREO Ee li TABLE OF CONTENTS—Continued B. Loss Of Affordable Health Insur- ance Generally Means Worse SRLS TERES RRS SEN nee 8 Ie re aS 14 C. The Subsidies’ Positive Effect On Health Insurance Access Promises To Improve The Nation’s Ability To Fight Epidemic Illnesses, In- I CET eitisniciicncisninitsddnsiniiniiinineiniaiienbsnabicsimsbeconaiine 19 1. HIV remains a serious public health threat, and insufficient insurance undermines HIV care and treatment .............:cccceceeeesseeeeeeeree 19 2. Massachusetts’s improvement in HIV health outcomes demonstrates the _ effective- ness of expanded health insur- ance coverage in fighting the I eceentsicrinicavictinnsitatiesnntinnnietainnnneneiennan 24 3. Reversal of the judgment be- low would undermine the Na- tion’s ability to address future epidemics and other emerging public health threats...........cccccseseeeerenees 27 CTE FEI seccasnissescatncietecermnesinicenencinammmnssannsenneneteitie 30 iii TABLE OF AUTHORITIES CASES National Federation of Independent Business v. Sebelius, 132 S. Ct. 2566 42 U.S.C. §§ 18081-18082 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 OTHER AUTHORITIES Abara, Winston, & Harry J. Heiman, The Affordable Care Act and Low-Income People Living With HIV: Looking Forward in 2014 and Beyond, 25 J. Ass’n Nurses in AIDS Care 476 (2014) Bagley, Nicholas, et al., Predicting the Fallout from King v. Burwell— Exchanges and the ACA, 372 New Enng. J. Med. 101 (2015)......cscscssessseessseeesseees SEE EEE EEE EEE EEE EEE SEER EEE EEE SESE EHS SHH HH HHT ee SOC SEES EEE EEE EEE EEE HETERO eee 2 BARES een oe oe Fe iiiceinsditesimisniadannsecnindadintatobininaiinisions ND stensicicresnicbniispncicaiceniiteinsaiiliiaiannniseni iv TABLE OF AUTHORITIES—Continued Blumberg, Linda J., et al., Characteristics of Those Affected by a Supreme Court Finding for the Plaintiff in King v. Burwell (Jan. 2015), available at http://www.urban.org/U ploadedPDF/ 2000078-Characteristics-of-Those- Affected-by-King-v-Burwell.pdf................. Blumberg, Linda J., et al, The Implications of a Supreme Court Finding for the Plaintiff im King v. Burwell (Jan. 2015), available at http//www.urban.org/UploadedPDF/ 2000062-The-I mplications-King-vs- Bordelon, Austin, et al., The Stage is Set: Predicting State and _ Federal Reactions to King v. Burwell (Jan. 2015), available at http://assets.fierce markets.net/public/healthcare/leavitt- partners-king-v-burwell. pdf ................:0000: Boutwell, Amy E., & Jonathan Freedman, Coverage Expansion and the Justice- Involved Population: Implications for Plans and Service Connectivity, 33 Health Affairs 482 (2014) .......--....:cceeceeseeees Bovbjerg, Randall R., & Frank C. Ullman, Recent Changes in Health Policy for Low-Income People in Massachusetts, 17 Urban Institute State Update 1 Page(s) Ras Teed id 13 v TABLE OF AUTHORITIES—Continued Page(s) Bradley, Heather, et al., Vital Signs: HIV Diagnosis, Care, and _ Treatment Among Persons Living with HIV— United States, 2011, 63 Morbidity & Mortality Wkly. Rep. 1113 (2014) .....0....... 19, 20 Cohen, Myron S., et al., Prevention of HIV- 1 Infection with Early Antiretroviral Therapy, 365 New Eng. J. Med. 493 EID shtiehenipatdnddiecasnisassatbncddcctupateneiucabnidtam meme 20 Cohen, Robin A., et al., Strategies Used by Adults to Reduce their Prescription Drug Costs, 119 NCHS Data Brief (2013), available at http://www.cdc. gov/nchs/data/databriefs/db119.pdf.............00......... 17 Cohen, Stacey M., et al., Vital Signs: HIV Prevention Through Care’ and Treatment— United States, 60 Morbidity & Mortality Wkly. Rep. 1618 ___, | RR Ono RED SSSt.., VAD Rieter SANT 26 Committee on Energy and Commerce, Minority Staff, District-by-District Impact of a Potential Supreme Court Ruling Against Affordable Care Act Federal Exchange Tax Credits (Dec. 2014), available at http://democrats. energycommerce.house.gov/sites/default/ files/documents/Fact-Sheet-District-By- District-King-vs-Burwell-Impacts-2014- vi TABLE OF AUTHORITIES—Continued Eibner, Christine, & Evan Saltzman, Assessing Alternative Modifications to the Affordable Care Act: Impact on Individual Market Premiums and Insurance Coverage (2014), available at http://www.rand.org/content/dam/rand/ pubs/research_reports/R R700/RR708/ RAND_RR7OB.pdf..e.sccsssssscsssessesceccccssesecensee Goldman, Dana P., et al. Effect of Insurance on Mortality in an HIV- Positive Population in Care, 96 J. Am. Statistical Ass’n 883 (2001) .................0..0000-. Goldman, Dana P., et al., The Prospect of a Generation Free of HIV May Be Within Reach if the Right Policy Decisions Are Made, 33 Health Affairs ERR SESE SR aie Renee ne cocnes eee Grewal, Andy S., How King v. Burwell Creates Tax Problems for 2014-2015 Health Care Enrollees, 32 Yale J. on Reg. Online (forthcoming), available at http://papers.ssrn.com/sol3/papers.cfm? abstract_id=2525951 (last visited Jan. 27, Hall, Mark A., & Richard Lord, Obamacare: What the Affordable Care Act Means for Patients and Physicians, BMJ 1 (2014), available at http://www.bmj. com/content/349/bm)j.g5376............-ccceseeees Page(s) jaieanield 1] Vil TABLE OF AUTHORITIES—Continued Page(s) Hall, Mark A., Disingenwous: The Latest Legal Challenges to Insurance Market Reforms, 44 Hastings Ctr. Rep. 6 (2014) ................. Hamel, Liz, et al., Survey of Non-Group Health Insurance Enrollees: A First Look At People Buying Their Own Health Insurance Following Imple- mentation of the Affordable Care Act (2014), available at https://kaiserfamily foundation.files.wordpress.com/2014/06/ survey-of-non-group-health-insurance- enrollees-findings-final 1 pdf ................ccccceceeeeeeeeeeees Harvard Law School Center for Health Law and Policy Innovation, Massachu- setts Case Study: Health Reforms in Conjunction with the Ryan White Program Lead to Improved Individual and Public Health Outcomes and Cost Savings (May 2014), available at http:// www.chipi.org/wp-content/uploads/2014/ 01/CHLPI-MA-Case-Study_5-28-14.pdf.........00....... Harvard Law School Center for Health Law and Policy Innovation, Massachu- setts Case Study: Health Reforms Lead to Improved Individual and Public Health Outcomes and Cost Savings (June 2012), available at http://www. law.harvard.edu/academics/clinical/sc/ documents/FACT_SHEET_%20MA_ Case_Study_on_Health_Reforms6-27- Vili TABLE OF AUTHORITIES—Continued HHS, Office of the Assistant Secretary for Planning and Evaluation, Health Insurance Marketplace 2015 Open Enrollment Period: December Enrollment Report (Dec. 2014), available at http-//aspe.hhs.gov/health/ reports/2014/MarketPlaceEnrollment/ Dec2014/ib_2014Dec_enrollment.pdf ........... Holman, Jeremy, et al., Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study (June 2011), available at http://www.mass.gov/eohhs/docs/dph/ aids/consumer-study-june-201 1.pdf.............. Institute of Medicine, A Shared Destiny: Community Effects of Uninsurance (2003), available at http://www.iom. edu/Reports/2003/A-Shared-Destiny- Community-Effects-of-Uninsurance. Institute of Medicine, America’s Uninsured Crisis: Consequences for Health and Health Care (2009), available at http:-// www.iom.edu/Reports/2009/A mericas- Uninsured-Crisis-Consequences-for- Health-and-Health-Care.aspx ..................000++ Page(s) ix TABLE OF AUTHORITIES—Continued Page(s) Jost, Timothy, Implementing Health Reform: A Summary Health Insurance Marketplace Enrollment Report, Health Affairs Blog (May 1, 2014), available at _ http://healthaffairs.org/ blog/2014/05/01/implementing-health- reform-a-summary-health-insurance- marketplace-enrollment-report ..............cccceeeeeeeeeeeeees 6 Kaiser Commission on Medicaid and the Uninsured, The Uninsured: A Primer: Key Facts About Health Insurance on the Eve of Health Reform (2013), available at http://files.kff.org/ attachment/the-uninsured-a-primer- key-facts-about-health-insurance-and- the-uninsured-in-america-primet ................++ 16, 17 Kates, Jennifer, et al., Assessing the Impact of the Affordable Care Act on Health Insurance Coverage of People with HIV (2014), available at https:// kaiserfamilyfoundation.files.wordpress. com/2013/12/8535-assessing-the- impact-of-the-affordable-care-act-on- health-insurance-coverage. pdf .............ccsccseeseeeeeeeenee 21 Levi, Jeffrey, et al., Outbreaks: Protecting America From Infectious Diseases (Dec. 2014), available at http://healthy americans.org/assets/files/Final%20 Outbreaks%202014%20Report. pdf ................. eee 28 Xx TABLE OF AUTHORITIES—Continued Levitt, Larry, & Gary Claxton, The Potential Side Effects of Halbig (July 31, 2014), available at http://kff.org/ health-reform/perspective/the- potential-side-effects-of-halbig’ ................... Lurie, Nicole, H1N1 Influenza, Public Health Preparedness, and Health Care Reform, 361 New Eng. J. Med. 843 Si caisieuaehindiiauininenanntemensessstinesenpnensessansenssosseseonsees Maciosek, Michael V., et al., Greater Use of Preventive Services in U.S. Health Care Could Save Lives At Little Or No Cost, 29 Health Affairs 1656 (2010) ............. McManus, Kathleen A., et al., Current Challenges to the United States’ AIDS Drug Assistance Program = and Possible Implications of the Affordable Care Act, 2013 AIDS Res. & a csienenenens McMorrow, Stacey, et al., Determinants of Receipt of Recommended Preventive Services: Implications for _ the Affordable Care Act, 104 Am. J. Pub. it a ectenecerescnsnastnvesenieseeesenensccoots Mugavero, Michael J., et al., The State of Engagement in HIV Care in the United States: From Cascade to Continuum to Control, 57 Clinical Infectious Diseases 1164 (2013)................... Page(s) phinhiimenaiin 13 =e 20, 21 xi TABLE OF AUTHORITIES—Continued Reeve, Megan, et al., The Impacts of the Affordable Care Act on Preparedness Resources and Programs: Workshop I Ge cintriccnseinntianntenneninmiainiiane Riley, Elise D., Population-Level Effects of Uninterrupted Health Insurance On Services Among HIV-Positive Unstably Housed Adults, 23 AIDS ON i aa Saltzman, Evan, & Christine Eibner, The, Effect of Eliminating the Affordable Care Act’s Tax Credits in Federally Facilitated Marketplaces (Jan. 2015), available at http://www.rand.org/ content/dam/rand/pubs/research_reports/ RR900/RR980/RAND_RR9S80.pdf ............ Snider, Julia Thornton, et al., Nearly 60,000 Uninsured and Low-Income People with HIV/AIDS Live in States that are not Expanding Medicaid, 33 Health REIS GG Ga cccceecetitinsinitntsiiaissecininnsiinnee Sommers, Benjamin D., et al., Changes in Mortality After Massachusetts Health Care Reform, 160 Annals of Internal Page(s) 21, 22, 27 GS. SE GD cscecieniniccistivcieinaniinniminain 15, 16, 25, 27 Sommers, Benjamin D., et al., Mortality and Access to Care among Adults after State Medicaid Expansions, 367 New Bing. J. MOG. 1GRD CIGD). ..wnccerreceecccocesecsessesse Gi TABLE OF AUTHORITIES—Continued Page(s) Sood, Neeraj, et al.. HIV Care Providers Emphasize the Importance of the Ryan White Program for Access to and Quality of Care, 33 Health Affairs 394 Van Der Wees, Philip J., et al, Improvements in Health Status after Massachusetts Health Care Reform, 91 Milbank Q. 663 (2013) ........c-cccco-coceoecuecseseeseesseseeenesoee 15 Vinter, Serena, et al., Public Health Preparedness in a Reforming Health System, 4 Harv. L. & Pol’y Rev. 339 ERR ee SP eee 5 OE en ee 29 Wagner, Zachary, et al., The Affordable Care Act May Increase the Number of People Getting Tested for HIV By Nearly 500,000 by 2017, 33 Health ee Ce Ce iirteteceittebiecciiteestasniiliniiaininietitrmapensinnin 27 INTEREST OF AMICI CURIAE' Amici are the Harvard Law School Center for Health Law and Policy Innovation; ADAP Advocacy Association; AID Atlanta, Inc.; AIDS Action Coalition of Huntsville; AIDS Action Committee of Massachu- setts; AIDS Alabama; AIDS Foundation of Chicago; AIDS Institute; AIDS Project Los Angeles; AIDS Resource Center of Wisconsin; AIDS Resource Center Ohio; AIDS United; American Academy of HIV Medi- cine; Association of Nurses in AIDS Care; Caracole, Inc.; Cascade AIDS Project; Center for HIV Law and Policy; Christie’s Place; Colorado Organizations Re- sponding to AIDS; Community Access National Net- work; Community Catalyst; Duke AIDS/HIV and Cancer Legal Project; Equality New Mexico; Gay Men’s Health Crisis; God’s Love We Deliver; Health- HIV; HIV Medicine Association; Illinois Coalition for Immigrant and Refugee Rights; Justice Resource In- stitute; Legacy Community Health Services; Lifelong; Los Angeles LGBT Center; Michigan Consumers for Healthcare; Nashville CARES; National Alliance of State and Territorial AIDS Directors; New Hamp- shire Voices for Health; NJ For Health Care; NO/AIDS Task Force; North Carolina AIDS Action Network; Ohio Public Health Association; Positive Women’s Network Colorado; Pozitively Healthy Coali- tion; Project Inform; Southern HIV/AIDS Strategy By letters on file with the Clerk, all parties have consented to the filing of this brief. Pursuant to Supreme Court Rule 37.6, amici state that no counsel for a party authored this brief in whole or in part; no counsel or party made a monetary contribution in- tended to fund the preparation or submission of this brief; and no person—other than 2:::\ci, their members, or their counsel—made such a monetary contribution. 2 Initiative; UHCAN Ohio; Whitman-Walker Health; and Women’s Collective. While each amicus has its own particular mission, they collectively serve populations that are deeply af- fected by the availability of federal subsidies under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010). Several amici are dedicated to addressing the needs and interests of peo- ple living with HIV and AIDS, and all amici have can speak to the harmful consequences that would result from a reversal in this case. Amici write: (1) to demonstrate that Congress’s provision in the ACA of federal subsidies to people who have gained access to insurance on the federal ex- changes accomplishes Congress’s goal of achieving near-universal coverage and improving the Nation’s health; (2) to explain the harms—to vulnerable popula- tions, middle- and low-income households, and higher- earning households alike—that Petitioners’ erroneous interpretation of the ACA would cause; and (3) to ex- plain the negative effect that Petitioners’ proposed in- terpretation of the ACA would have on the national ability to respond to public health threats, such as the HIV epidemic, the Ebola virus, pandemic flu, or other as-yet unanticipated public health crises. SUMMARY OF ARGUMENT One of the central pillars of the ACA is Congress’s creation of health insurance exchanges, which expand- ed access to the private individual health insurance market for households that do not receive employer- sponsored or public health insurance coverage. 42 U.S.C. § 18091(2)(D), (1I)-{J). As the Act’s structure demonstrates, Congress understood that ensuring na- 3 tionwide access to affordable health insurance requires eliminating discriminatory practices, mandating cover- age to achieve broad insurance risk pools, and extend- ing subsidies to middle- and low-income Americans who cannot afford to purchase coverage on their own. To- gether, the ACA’s insurance market reforms, individu- al mandate, and subsidies have yielded the Act’s core achievement: transforming the private health insurance markets in all 50 States and the District of Columbia such that nearly all Americans now have access to health insurance. The government persuasively demonstrates, and the court of appeals correctly held, that the language, structure, and purpose of the Act reveal Congress’s aim to permit the use of federal subsidies even in States that decline to establish State exchanges. Those arguments will not be repeated here. Amici write to explain that it makes eminent sense that Congress would have provided for such a scenario, and that available data show that the ACA is accomplish- ing Congress’s goal of achieving “near-universal” ac- cess to quality health insurance coverage. 42 U.S.C. § 18091(2)(D). Early results include dramatic expan- sions of health insurance access among middle- and low-income households and significant reforms in the private insurance market that benefit exchange par- ticipants of all income levels nationwide. Health in- surance plans are now more comprehensive, premium prices have remained stable, and discriminatory insur- ance coverage practices are prohibited. Importantly, increased access to health insurance benefits not only the newly insured, but the Nation as a whole, as Congress intended. This brief reports evi- dence of both types of success. First, Congress’s achievement of its goal is reflected in accounts of indi- 4 viduals and families whose lives are transformed be- cause—through the subsidies available in all States— they can now obtain the health care they need and are less subject to financial insecurity. Second, the ACA’s expansion of health insurance access in all States prom- ises to improve the national ability to respond to epi- demics and other large-scale public health threats, just as health insurance access improved the ability of States with broad health insurance to combat the HIV epidemic. The negative results of a reversal in this case go well beyond “adverse policy consequences.” Pet. Br. 15. Rather, the evidence shows that Petitioners’ pro- posed interpretation of the ACA would render a sig- nificant provision of the Act ineffective in a majority of States. There is no reason to interpret the Act to render the federal exchanges inoperative, depriving millions of people of access to the health insurance on which they now depend, when Congress plainly in- tended to bring about the very improvements in indi- vidual, familial, and national health care that the ACA has provided when interpreted as the Internal Reve- nue Service and the Fourth Circuit have interpreted it. This Court should affirm the judgment of the court of appeals. oD ARGUMENT REVERSAL OF THE JUDGMENT BELOW WOULD DEPRIVE MILLIONS OF RECENTLY INSURED AMERICANS OF NEW- FounD ACCESS TO HEALTH INSURANCE, SERIOUSLY THREATEN HEALTH QUTCOMES, AND UNDERM'NE THE NATION'S ABILITY TO ADDRESS EPIDEMICS AX OTHER PUBLIC HEALTH THREATS A. The ACA’s Provision Of Federal Subsidies In All States Has Dramatically Improved Health Insurance Access And Is Integral To The Act’s Insurance Market Reforms The ACA’s overall impact on the U.S. health care landscape cannot yet be definitively assessed, but the Act has already transformed the private individual health insurance markets nationwide by significantly expanding access among middle- and low-income households and by reforming these markets for all par- ticipants. But if individuals and families in 34 States lose access to federal subsidies—as Petitioners would have it—then health insurance would once again be- come unaffordable for many, and the federal health in- surance exchanges would likely collapse. As a result, the individuals and families who have gained so much under the Act would personally suffer the consequenc- es: Millions of middle- and low-income households would lose access to health insurance altogether, and millions more would have to pay significantly higher premiums to maintain coverage. 1. The ACA’s subsidies have yielded un- precedented gains in insurance access among middle- and low-income house- holds Before the ACA’s premium subsidies, middle- and low-income Americans had great difficulty obtaining 6 affordable health insurance coverage. Millions of households could not access affordable health insurance through their employer, were ineligible for Medicaid and Medicare, and were excluded by—or simply could not afford—plans offered on the private individual market. See Hall & Lord, Obamacare: What the Af- fordable Care Act Means for Patients and Physicians, BMJ 1, 2 (2014). The 2014 launch of the ACA’s health insurance exchanges brought a sea change, as every household with an income between 100 and 400 per- cent of the Federal Poverty Level (FPL) (between $11,670 and $46,680 for an individual, and between $23,850 and $95,400 for a family of four in 2014) could access comprehensive health insurance, regardless of employment, place of residence, or health status. Notwithstanding a rollout plagued by technical difficul- ties, 8 million people nationwide enrolled in exchange health plans during the 2014 open enrollment period, with over 6.7 million individuals (85 percent) obtaining access to affordable insurance through subsidies. Jost, Implementing Health Reform: A Summary Health In- surance Marketplace Enrollment Report, Health Af- fairs Blog (May 1, 2014). The transition from being uninsured or underin- sured to being adequately insured with the help of fed- eral subsidies can be life-changing. For example, Phil Sherburne, 43, and his wife Leia Bell, 37, own a small business in Salt Lake City.? Because of a preexisting shoulder injury, Mr. Sherburne had been unable to ac- cess affordable insurance through the individual mar- * The personal accounts reported in this brief were obtained through personal interviews conducted by the Harvard Law School Center for Health Law and Policy Innovation and are used with permission of the individuals involved. 7 ket for himself, his family, or the employees of his small business. Many insurers denied him family and small- group coverage altogether; others only offered plans with prohibitively high premiums. When his family was uninsured, Mr. Sherburne could not obtain treat- ment for his injured shoulder, Ms. Bell could not obtain diagnostic tests for persistent abdominal pain, and the couple had to pay out-of-pocket for all health care for their three sons, ages 13, 10, and 8. In 2014, after implementation of the ACA, Mr. Sherburne enrolled his family in a health insurance plan through the federally operated exchange in Utah. Mr. Sherburne and Ms. Bell were eligible for subsidies be- cause their projected income was $40,000, or less than 150 percent FPL. With subsidies, the entire family was covered for a premium of just $123 per month; without subsidies, the monthly premium would have been $850. Immediately after becoming insured through the ACA, Mr. Sherburne received his first physical examination in over a decade, visited a dermatologist for cancer screening, and obtained physical therapy that improved his shoulder injury and, hi. doctor believes, likely elim- inated the need for future surgery. Once she became insured, Ms. Bell was able to see a doctor about her ab- dominal pain and, as a result, received surgery to re- move her gallbladder just three days later. The sur- gery was successful; for the first time in her adult life, Ms. Bell no longer suffers from chronic pain. Mr. Sher- burne and Ms. Bell also no longer have to pay out-of- pocket health expenses for their three children. When their son recently broke his thumb, his emergency care and cast were both covered. Mr. Sherburne and Ms. Bell renewed their health insurance plan on Utah’s federal exchange for 2015, and their premium payments remain a low $174, com- 8 pared to the $805 they would have to pay without sub- sidies. Without access to their $631 monthly subsidy, Mr. Sherburne and Ms. Bell would be forced to cancel their family’s health insurance coverage. Mr. Sher- burne and Ms. Bell cannot pay themselves a higher salary without jeopardizing their business; they both drive used cars and have no monthly car payment; their children already wear hand-me-down clothing; and they do not take family vacations. Their budget simply could not accommodate the $9660 annual pre- mium that Petitioners’ interpretation of the Act would require them to pay. Lisa Paterson, 60, who is self-employed and lives in Moab, Utah, likewise could not access or afford com- prehensive health insurance on the individual market until the ACA’s subsidies made it possible. For four years prior to the ACA, she delayed obtaining the health care she needed because of coverage and cost issues. Ms. Paterson was denied access to comprehen- sive coverage on the individual market because she suf- fers from preexisting conditions, including an autoim- mune disease, osteoporosis, and a previously torn ante- rior cruciate ligament. Only by depleting her savings account was she able to purchase a high-deductible cat- astrophic insurance plan, which had a premium of ap- proximately $330 per month and a $7000 deductible. In 2014, however, Ms. Paterson signed up for a comprehensive HMO plan through Utah’s federally run exchange that, after subsidies, cost her only $16.90 per month. Without the subsidies, Ms. Paterson’s monthly premium costs would have been $475.34. In 2014, this comprehensive plan enabled Ms. Paterson to visit her primary care physician four times to monitor her condi- tions and obtain all recommended preventive care. Af- ter a routine mammogram revealed a suspicious mass, 9 Ms. Paterson received diagnostic testing at a world- renowned cancer institute. During the 2015 open en- rollment period, Ms. Paterson purchased a new insur- ance plan on Utah’s federally run exchange and, be- cause she earns less than 133 percent FPL, she now pays just $26.30 for her monthly premium costs, com- pared to the $501.30 she would have to pay without subsidies. If she loses access to this $475 monthly sub- sidy, Ms. Paterson’s only option for maintaining insur- ance coverage that costs $6015 annually would be to withdraw funds from her retirement account. As the 2015 open enrollment period is still under- way, complete enrollment data are not yet available. But preliminary data indicate that subsidies will once again enable millions of middle- and low-income Ameri- cans to obtain affordable health insurance coverage in States using federal exchanges. HHS, Office of the As- sistant Secretary for Planning and Evaluation, Health Insurance Marketplace 2015 Open Enrollment Period: December Enrollment Report 23 (Dec. 2014). Accord- ingly, all indications are that the subsidies will continue to play a critical role in reducing the number of unin- sured Americans. 2. The subsidies are integral to maintaining insurance market reforms for all ex- change participants The ACA’s subsidies are important not only to those who qualify for them, but also to those who do not. Households that do not qualify for subsidies none- theless benefit substantially from the ACA’s reforms to the individual health insurance market, to which the subsidies are integral. Those reforms—which apply to all insureds regardless of whether they receive subsi- dies—have improved health insurance by ensuring con- 10 sumer protections, expanding health benefits coverage, and making the individual health insurance market more user-friendly. For many, those reforms have also led to an increase in the number of insurance plan offer- ings and insurers available. The ACA’s reforms provide that insurers cannot exclude coverage for preexisting conditions, arbitrarily rescind coverage, or base premium rates on an individ- ual’s health status. Hall & Lord, Obamacare at 3. Plan offerings are also far more comprehensive. Before the ACA, only 2 percent of health plans offered on the indi- vidual market covered all ten of the “Essential Health Benefit” categories that the ACA now requires. Boutwell & Freedman, Coverage Expansion and the Justice-Involved Population: Implications for Plans and Service Connectivity, 33 Health Affairs 482, 483- 484 (2014). Purchasing health insurance on the ex- changes is also far easier because insurers are now con- solidated into a single marketplace. Further, because insurance plan offerings are now standardized into cov- erage tiers with defined levels of cost sharing—bronze, silver, gold, and platinum—consumers can more readily compare plans among competing insurers. Hall & Lord, Obamacare at 3. For many, the exchanges offer more competitive plan offerings and prices than private insur- ers offered before the ACA, with new insurers entering the individual markets in response to the opportunity for increased enrollment on the exchanges. /d. at 6. Congress understood, however, that the individual market could not be substantially improved solely through regulation of insurers. 42 U.S.C. § 18091(2)(1)- (J). To ensure that the ACA’s insurance regulations do not cause healthy people to defer purchasing insurance until they are sick, Congress established the “individual! mandate”—the requirement that every person either i} purchase health insurance or pay a tax penalty. 26 U.S.C. § 5000A; National Fed’n of Indep. Bus. v. Sebe- lius, 132 S. Ct. 2566, 2577, 2580 (2012) (plurality opin- ion). Congress also ensured that those who are subject to the individual mandate could afford insurance by providing federal subsidies. 42 U.S.C. §§ 18081-18082; 26 U.S.C. § 36B. Together, the individual mandate and federal subsidies have achieved broad insurance cover- age nationwide, enabling insurers to offer the ACA’s improved insurance products at affordable premiums. See Hall & Lord, Obamacare at 6. The individual mandate and subsidies are interde- pendent. Congress exempted from the individual man- date households that cannot access affordable health in- surance. 26 U.S.C. § 5000A(e)(1)(A). In the absence of federal subsidies, many households in States using fed- eral exchanges would become exempt from the individu- al mandate because they would no longer have access to affordable insurance. See Blumberg et al., The Implica- tions of a Supreme Court Finding for the Plaintiff in King v. Burwell 6 (Jan. 2015). Removing the subsidy- eligible population from the exchanges’ coverage group would subsequently affect the availability of affordable insurance for higher-earning households. A recent study predicts that eliminating the ACA subsidies would cause a near “death spiral,” a cycle of sharp premium increases and subsequent disenrollment until only the sickest in- dividuals remain in the market risk pools. Eibner & Saltzman, Assessing Alternative Modifications to the Affordable Care Act: Impact on Individual Market Premiums and Insurance Coverage 25 (2014). A death spiral would result in insurance becoming unaffordable for many higher-earning households, thereby exempting an even greater population from the individual mandate. See Hall, Disingenuous: The Latest Legal Challenges to 12 Insurance Market Reforms, 44 Hastings Ctr. Rep. 6, 6-7 (2014). The study demonstrates that subsidies are es- sential to preserving the economic viability of the ACA’s reforms to the individual health insurance market na- tionwide. Thus, the ACA’s subsidies are significant even to those who do not qualify for them because, in the ab- sence of subsidies, many higher-earning households would also lose access to the ACA’s improved insurance products. 3. Insurance access gains and market re- forms in most States would be lost if the decision below is reversed Since its full implementation began just one year ago, the ACA has already reduced significantly the number of uninsured American households and trans- formed the individual health insurance markets in al] 50 States and the District of Columbia. Implementation is an ongoing process for the federal government, States, insurers, health care providers, and households nation- wide, and promises to continue to improve health care in the United States for years to come, provided the Act’s intended scheme remains in place. However, if households in 34 States lose access to subsidies, then the Act’s scheme would collapse in these States, and middle- and low-income households would lose everything they gained under the ACA. See Bor- delon et al., The Stage is Set: Predicting Staie and Fed- eral Reactions to King v. Burwell 5 (Jan. 2015) (eliminat- ing subsidies would “deliver a crippling blow to the health care law and tarnish much of the implementation progress that has been made to date”). Of the 6.7 million individuals who relied on subsidies to access health in- surance during the 2014 enrollment cycle, 4.6 million live in States where federal exchanges operate; most, if not 13 all, of those people would see their new-found insurance become immediately unaffordable. Levitt & Claxton, The Potential Side Effects of Halbig (July 31, 2014); see also Blumberg et al., Characteristics of Those Affected by a Supreme Court Finding for the Plaintiff in King v. Burwell 7 (Jan. 2015) (predicting that 99 percent of the subsidy-eligible population would face unaffordable premiums following a ruling for Petitioners). These households, including the Sherburne family and Lisa Paterson in Utah, see supra pp. 6-9, would be forced to drop coverage immediately or face an average monthly premium increase of $400. See Committee on Energy and Commerce, Minority Staff, District-by-District Im- pact of a Potential Supreme Court Ruling Against Af- fordable Care Act Federal Exchange Tax Credits 1 (Dec. 2014). The millions of affected households could also encounter devastating liability on their 2015 tax re- turn. See Grewal, How King v. Burwell May Create Tax Problems for 2014-2015 Health Care Enrollees, 32 Yale J. on Reg. Online (forthcoming). By 2016, the total num- ber of middle- and low-income Americans denied access to subsidies could reach 13 million. Committee on Ener- gy and Commerce, District-by-District Impact at 1. Petitioners’ argument would not only harm middle- and low-income Americans, but also higher-earning Americans who rely on the individual market to access insurance in the affected States. A recent RAi*!) Cor- poration study predicts that eliminating the ACA sub- sidies in the 34 States using federal exchanges would result in substantial unsubsidized premium increases and exchange-wide enrollment declines. Saltzman & Eibner, The Effect of Eliminating the Affordable Care Act’s Tax Credits in Federally Facilitated Marketplac- es 5 (Jan. 2015). This study estimates that, without federal subsidies, wnsubsidized premiums on the feder- 14 ally operated exchanges would rise 47 percent, and an estimated 9.6 million people would lose insurance cov- erage. Id. This represents a 70 percent decrease in current federal exchange enrollment and includes high- er-earning households as well as_ subsidy-eligible households. Jd. The projected premium increases and disenrollment would threaten the ultimate viability of the federal exchanges. /d. at 6. Petitioners’ argument would thus harm higher-earning Americans who access insurance on the federal exchanges by nearly doubling their premium rates and destabilizing the insurance market on which they rely. Even if States were to pursue implementing State- based exchanges immediately after losing federal sub- sidies, that is unlikely to prevent an immediate destabi- lization of the insurance markets in those States. See Bagley et al., Predicting the Fallout from King v. Bur- well—Ezchanges and the ACA, 372 New Eng. J. Med. 101 (2015). States would face significant obstacles to establishing State-based exchanges, including the con- siderable time and resources required, extensive statu- tory and regulatory requirements, technological] chal- lenges, and the timing of State legislative sessions. /d. at 101-102. If this Court reverses the court of appeals’ judgment, it is highly unlikely that States could establish new State-based exchanges before the vast majority of enrollees were faced with soaring premium costs. See supra pp. 12-13. Reversal could therefore prevent mil- lions of Americans from obtaining health insurance for years. See Bagley et al., 372 New Eng. J. Med. at 103. B. Loss Of Affordable Health Insurance Gener- ally Means Worse Health By increasing access to and improving health care coverage, the ACA’s health insurance exchanges have 15 promoted health outcomes among Americans nation- wide. Reversal of the judgment below would not only undermine the Act’s statutory scheme, but would also threaten the well-being and longevity of millions of people with serious health care needs. Having health insurance is associated with im- provements in self-reported physical and mental health status and an increased use of preventive care. See Van Der Wees et al., Improvements in Health Status after Massachusetts Health Care Reform, 91 Milbank Q. 663, 676-678 (2013). Recent studies estimate that expanded access to health insurance decreases annual mortality rates by at least 2.9 percent. Compare Som- mers et al., Changes in Mortality After Massachusetts Health Care Reform, 160 Annals of Internal Med. 585 (2014), with Sommers et al., Mortality and Access to Care among Adults after State Medicaid Expansions, 367 New Eng. J. Med. 1025 (2012). These findings sug- gest that, by the end of the open enrollment period in February 2015, at least one death will be prevented for every thousand adults who gained insurance access on the exchanges in 2014. See Sommers et al., 160 Annals of Internal Med. at 591; Sommers et al., 367 New Eng. J. Med at 1031. One study estimates that 57 percent of the 8 million people who purchased insurance on the exchanges in 2014 were previously uninsured. Hamel et al., Survey of Non-Group Health Insurance Enrol- lees: A First Look At People Buying Their Own Health Insurance Following Implementation of the Affordable Care Act 6 (2014). Accordingly, this evidence suggests that, after just one enrollment year, expanding cover- age through the ACA’s health insurance exchanges will have saved thousands of lives. The positive effect of health insurance on health outcomes is partially explained by the increased access 16 to, and utilization of, health care services. Adequately insured adults are more likely to receive regular pre- ventive care, which increases the likelihood of timely diagnosis and treatment. McMorrow et al., Determi- nants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act, 104 Am. J. Pub. Health 2392, 2396-2398 (2014). Preventive care services tend to be low-cost and cost effective; one study estimates that increasing access to preventive care in the U.S. could save nearly $ billion annually by improving population health and reducing medica) spending. Maciosek et al., Greater Use of Preventive Services in U.S. Health Care Could Save Lives At Lit- tle Or No Cost, 29 Health Affairs 1656, 1658 (2010). Adults with health insurance are also more likely to comply with prescribed treatment regimens and follow- up care, which contribute to better overall health. McMorrow et al., 104 Am. J. Pub. Health at 2396-2398. Most significantly, health insurance saves the lives of people who suffer from conditions that are preventable or treatable if they are identified early, such as certain cancers, infections, and heart disease. See Sommers et al., 160 Annals of Internal Med. at 591. In contrast, uninsured people have greater difficul- ty obtaining the care they need. In 2013, 25 percent of adults without insurance reported going without care in the previous year, largely due to cost, compared to only 4 percent of adults with coverage. See Kaiser Commis- sion on Medicaid and the Uninsured, The Uninsured: A Primer: Key Facts About Health Insurance on the Eve of Health Reform 6 (2013). Uninsured adults receive significantly less preventive care than adults with health insurance, leading to delayed or forgone treat- ment, later-stage cancer diagnoses, onset of acute con- ditions such as heart attack or stroke, and premature 17 death. Institute of Medicine, America’s Uninsured Crisis: Consequences for Health and Health Care 68-73 (2009). The uninsured are also more likely to forgo pre- scribed medications and less likely than insured indi- viduals to obtain all recommended health care services. Cohen et al., Strategies Used by Adults to Reduce their Prescription Drug Costs, 119 NCHS Data Brief 1, 1-6 (2013). Overall, a substantial body of evidence shows that uninsured individuals suffer worse health out- comes, including higher mortality rates, because of in- sufficient access to the health care system. See Kaiser Commission on Medicaid and the Uninsured, Unin- sured: A Primer at 11-12. The example of Kimberly Tonyan, 42, of Cornelius, North Carolina, illustrates the point. For years as a working single mother, Ms. Tonyan was unable to af- ford health insurance for herself and her two daugh- ters. Although Ms. Tonyan took her daughters for check-ups, she herself had not received annual exams or screenings, such as physicals or pap smears, for years, because she could not afford them. Although North Carolina has not established its own exchange, in 2014 she was able to sign up for health insurance through a federally run exchange. Due to her income of approximately $20,000, or less than 133 percent FPL, she was eligible for subsidies that brought the cost of her premiums down from $279 to $27.91 per month, saving her $3013.08 in annual premium costs. A few months later, Ms. Tonyan began experienc- ing pain in her abdomen. Because she was now insured, she visited a doctor, who diagnosed her with uterine fibroid tumors and an ovarian cyst. After she had a hysterectomy, her doctors discovered that she had en- dometrial cancer. Luckily, the cancer was caught and removed early, which meant there was no need for 18 more extensive and expensive treatment, such as chemotherapy or radiation. Moreover, because endo- metrial cancer is rare in women in their 40s, Ms. To- nyan’s doctor recommended genetic testing. This test- ing revealed that Ms. Tonyan has Cowden syndrome, a genetic condition associated with a greatly increased risk of breast, thyroid, uterine, and kidney cancer. Be- cause she now knows that she has an 85 percent risk of developing breast cancer, Ms. Tonyan chose to have a preventive mastectomy. Ms. Tonyan credits the ACA with saving her life. Without the subsidies that made it possible for her to purchase insurance on a federally operated exchange in North Carolina, Ms. Tonyan would not have gone to the doctor when she began experiencing pain in her ab- domen and might not have sought treatment until the cancer had spread much further. It is also unlikely that she would have sought testing for Cowden syndrome if she lacked comprehensive health insurance, which would have left Ms. Tonyan unaware of her increased risk for breast cancer and unable to pursue the preven- tive measures she has taken to preserve her health. Because Cowden syndrome is genetic, Ms. Tonyan’s di- agnosis is also important for preserving the health of her daughters, who can now pursue genetic testing and preventive measures before their health is at risk. The ACA’s health insurance exchanges and subsi- dies have already improved health and saved lives. * Because Ms. Tonyan’s health issues have affected her ability to work, she now earns less than 100 percent FPL. Accordingly, she did not qualify for a federal subsidy for the 2015 open enroll- ment period. Since North Carolina opted out of the ACA’s Medi- caid expansion, Ms. Tonyan is currently without access to afforda- ble health insurance. 19 Withholding subsidies from the 34 States using federal- ly operated exchanges would threaten the health of the subsidy-eligible population and higher-earning house- holds alike. Some would lose newly acquired coverage that has already dramatically improved their health. Others, who rely on the individual market to purchase insurance, would lose access to care if premium rates spiral and they are priced out of the market. The Court should not construe the Act in a way that would dis- mantle large portions of the statute and prevent mil- lions of people from obtaining the health care they need and that Congress sought to make available. C. The Subsidies’ Positive Effect On Health In- surance Access Promises To Improve The Nation's Ability To Fight Epidemic Illnesses, Including HIV Congress’s provision for tax subsidies nationwide also promises an additional national impact: improve- ment of the population’s ability to resist epidemic ill- nesses. The response to the HIV epidemic—which is the subject of extensive data and analysis—has provid- ed a valuable case study for the effect of expanded ac- cess to health insurance on the societal ability to ad- dress nationwide epidemics—including not only HIV, but future potential epidemics like the Ebola virus or pandemic flu. 1. HIV remains a serious public health threat, and insufficient insurance under- mines HIV care and treatment An estimated 1.2 million people in this country live with HIV, approximately 168,000 people are unaware of their infection, and, with each passing year, about 50,000 people become newly infected. See Bradley et 20 al., Vital Signs: HIV Diagnosis, Care, and Treatment Among Persons Living with HIV—United States, 2011, 63 Morbidity & Mortality Wkly. Rep. 1113, 1114 (2014). It need not be this way. Advancements in medical treatment have vastly improved the length and quality of life for people living with HIV and reduced the like- lihood of transmitting the virus to others—but these benefits are only realized by those who can receive sus- tained clinical care. See Goldman et al., The Prospect of a Generation Free of HIV May Be Within Reach if the Right Policy Decisions Are Made, 33 Health Affairs 428 (2014). The goal of HIV clinical care is to move pa- tients along a “continuum of care” from infection to di- agnosis, engagement in medical care, treatment, and, ultimately, viral suppression. Viral suppression helps people with HIV live longer, healthier lives because suppression preserves the immune system, slows the virus’s evolution, and reduces the risk of drug re- sistance. Cohen et al., Prevention of HIV-1 Infection with Early Antiretroviral Therapy, 365 New Eng. J. Med. 493, 503 (2011). Further, at the viral suppression stage, an individual’s ability to transmit HIV to others is reduced by 96 percent, significantly slowing the spread of the epidemic. /d. Achieving viral suppression is attainable for the majority of people who receive comprehensive and co- ordinated care, with recent studies finding that over 80 percent of people living with HIV who receive regular health care are virally suppressed. Mugavero et al., The State of Engagement in HIV Care in the United States: From Cascade to Continuum to Control, 57 Clinical Infectious Diseases 1164, 1164 (2013); Bradley et al., 63 Morbidity & Mortality Wkly. Rep. at 1115. Unfortunately, just 25 percent of Americans living with HIV are virally suppressed. Mugavero et al., 57 Clini- 21 cal Infectious Diseases at 1164. A lack of access to health insurance is strongly associated with this low overall rate of viral suppression, see id., while having health insurance is associated with a 71 percent reduc- tion in mortality among this population, Goldman et al., Effect of Insurance on Mortality in an HIV-Positive Population in Care, 96 J. Am. Statistical Ass’n. 883, 888 (2001). The HIV care necessary to treat the virus and im- pede its transmission is costly. Comprehensive insur- ance coverage is accordingly essential to promote indi- vidual and public health outcomes and to control—and eventually eliminate—this domestic epidemic. As re- cently as 2010, only 17 percent of people living with HIV had private health insurance, compared with 65 percent of the American population. Snider et al., Nearly 60,000 Uninsured and Low-Income People with HIV/AIDS Live in States that are not Expanding Med- icaid, 33 Health Affairs 386, 386 (2014). Before the ACA, many people living with HIV were denied pri- vate health insurance due to preexisting conditions, of- fered prohibitively high premium rates because of their diagnosis, or subjected to annual or lifetime caps on coverage. Kates et al., Assessing the Impact of the Af- fordable Care Act on Health Insurance Coverage of People with HIV 4 (2014). Some uninsured people living with HIV receive treatment assistance through public programs. For in- stance, the Ryan White Program, administered by the Department of Health and Human Services as a “payer of last resort,” provides limited funding to cities, States, and community-based organizations that offer health care and other services to people living with HIV. Sood et al., HIV Care Providers Emphasize the Importance of the Ryan White Program for Access to 22 and Quality of Care, 33 Health Affairs 394, 394-395 (2014). The Ryan White Program funds State- administered AIDS Drug Assistance Programs (ADAPs), which provide individuals who are uninsured or underinsured with prescription drugs for treating HIV. McManus et al., Current Challenges to the Unit- ed States’ AIDS Drug Assistance Program and Possi- ble Implications of the Affordable Care Act, 2013 AIDS Res. & Treatment 1, 1. These programs have never met the needs of all people seeking services; before the ACA, demand for ADAPs ballooned to over 225,000 people living with HIV nationwide. Jd. at 2. ADAP coverage and eligibility requirements vary widely by State, and many programs have waiting lists for new patients and quantity limits on prescription drug ac- cess. See Snider et al., 33 Health Affairs at 391. The Ryan White Program and ADAPs are not de- signed to function as health insurance plans that pro- vide coverage for a prescribed set of benefits; instead, they focus their limited resources on a core set of HIV services. See Snider et al., 33 Health Affairs at 391. People living with HIV have an increased risk and prevalence of comorbidities like cardiovascular disease and diabetes, and many require comprehensive insur- ance coverage that includes preventive and acute care to improve their health and quality of life. Abara & Heiman, The Affordable Care Act and Low-Income People Living With HIV: Looking Forward in 2014 and Beyond, 25 J. Ass’n Nurses in AIDS Care 476, 478 (2014). Coverage through the Ryan White Program and ADAPs simply cannot address these additional health needs. Again, an example illustrates the point. Tod Haley, 43, of Greensboro, North Carolina, is a loss prevention auditor. Prior to the ACA, Mr. Haley had been unin- 23 sured since 2007, when his insurer cancelled his health insurance policy after he suffered a herniated disk. In 2008, Mr. Haley, who already could not access insur- ance because of his preexisting spine injury, was diag- nosed with HIV. While he was uninsured, Mr. Haley was able to obtain HIV medications through North Carolina’s ADAP. However, Mr. Haley perpetually faced losing access to his life-saving treatment because he had to reapply for ADAP coverage every six months. On several occasions, Mr. Haley was unable to obtain his HIV medications through ADAP because he was waitlisted for coverage. Furthermore, in order to remain eligible for ADAP, Mr. Haley could not earn more than 250 percent FPL. Mr. Haley turned down several employment opportunities in his profession and instead sought minimum-wage positions to ensure that he could continue to obtain his HIV medications. Because of the ACA, Mr. Haley no longer faces the insecurity of the ADAP renewal process, and he no longer has to choose between advancing his career and receiving his HIV treatment. In 2014, Mr. Haley signed up for health insurance on North Carolina’s fed- erally run exchange. During the 2015 open enrollment period, he purchased a new plan offered by Blue Cross Blue Shield. Because of his income of approximately $20,000, or less than 200 percent of FPL, Mr. Haley is now eligible for an ACA subsidy that lowers his month- ly premiums to $158 per month from approximately $360. His copayments to see physicians range between $5 and $10, and he pays approximately $15 per month total for his HIV medications. Mr. Haley estimates that his monthly costs for these medications would be approximately $3700 without coverage. Because of his comprehensive coverage, Mr. Haley misses fewer doses of his HIV medications, receives al] recommended pre- 24 ventive care, and obtains ongoing care from a specialist for his herniated disk. If the Fourth Circuit’s judgment in this case is overturned, Mr. Haley would lose access to comprehensive health insurance. As a result, he would once again depend on North Carolina’s ADAP to access his HIV medications. People living with HIV who gained comprehensive coverage through the federal exchanges and subsidies in 34 States would suffer disproportionately if they lose health insurance access. Research demonstrates that uninterrupted health insurance is essential to achieving positive health outcomes for people in HIV treatment. Riley, Population-Level Effects of Uninterrupted Health Insurance On Services Among HIV-Positive Unstably Housed Adults, 23 AIDS Care 822 (2011). If the decision below is reversed and subsidies become unavailable in a majority of States, people living with HIV who lose access to subsidies or become priced out of failing federal exchanges could suffer harmful treat- ment disruptions that threaten their lives. These indi- viduals would once again rely on safety-net programs, which were already inadequate before the ACA. Sood et al., 33 Health Affairs at 395. 2. Massachusetts’s improvement in HIV health outcomes demonstrates the effec- tiveness of expanded health insurance coverage in fighting the epidemic New evidence from Massachusetts demonstrates that expanded heaith insurance has a proven effect in controlling the HIV epidemic. In 2006, Massachusetts achieved near-universal health insurance coverage by passing a comprehensive health reform law that ex- 25 panded Medicaid,’ offered subsidized private insur- ance, and enacted an individual mandate requiring all Massachusetts residents to purchase health insurance coverage; the Massachusetts statute later served as a model for the ACA. Sommers et al., 160 Annals of In- ternal Med. at 585; see also 42 U.S.C. § 18091(2)(1). Largely as a result of increased coverage, both indi- vidual and public health outcomes in Massachusetts are dramatically improved compared to national HIV- related statistics. Harvard Law School Center for Health Law and Policy Innovation, Massachusetts Case Study: Health Reforms Lead to Improved Indi- vidual and Public Health Outcomes and Cost Savings (June 2012). One study found that, between 2006 and 2009, new HIV diagnoses fell by 25 percent in Massa- chusetts as compared to a 2 percent increase nation- wide. Jd. A more recent study shows that, from 2000 to 2011, the number of HIV-related deaths in Massa- chusetts declined by 41 percent and the number of HIV infection diagnoses decreased by 44 percent. Harvard Law School Center for Health Law and Policy Innovation, Massachusetts Case Study: Health Re- forms in Conjunction with the Ryan White Program Lead to Improved Individual and Public Health Out- comes and Cost Savings (May 2014). In contrast, na- tionwide statistics for HIV-related deaths and new HIV diagnoses remained relatively unchanged. /d. People living with HIV in Massachusetts are also far more likely to progress along the HIV continuum of care than people living with HIV nationwide. Id.; see * In 2001, Massachusetts expanded Medicaid coverage to pre- disabled people living with HIV whose income was less than 200 percent FPL ($23,340 for an individual in 2014). Bovbjerg & Ullman, Recent Changes in Health Policy for Low-Income People in Massachusetts, 17 Urban Institute State Update 1, 14 (2002). 26 also supra p. 20. The following chart compares the percentages of people living with HIV in Massachu- setts who are diagnosed, receive regular medical care, take HIV medications, and are virally suppressed to the percentages of people living with HIV nationwide. Massachusetts Outcomes vs. National Outcomes’ 100 ° MA outcomes Natmonal oufcores Infected Dugnosed in Mecca! Bhung HIV Virally Care Metbaateens Supressed Extending health insurance coverage to people living with HIV has made a measurable difference in Massachusetts’s ability to combat the HIV epidemic. Congress’s adoption of subsidies and private health insurance reform has created a national capacity to * This chart, prepared by the Harvard Law School Center for Health Law and Policy Innovation, reports Massachusetts data from Holman et al., Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study (June 2011), and national data from Cohen et al., Vital Signs: HIV Prevention Through Care and Treatment—United States, 60 Morbidity & Mortality Wkly. Rep. 1618 (2011). 27 replicate Massachusetts’s successes.” One study esti- mates that, by 2017, increased access to preventive care under the ACA will result in an additional 466,153 HIV screenings, leading to 2598 new diagnoses and reducing the number of people who are unaware of their HIV status by 22 percent. Wagner et al., The Affordable Care Act May Increase the Number of People Getting Tested for HIV By Nearly 500,000 by 2017, 33 Health Affairs 378, 384 (2014). By making coverage for HIV testing and treatment available, the ACA will ensure that more people living with HIV will be diagnosed, more will discover their status ear- lier, more will initiate care, and more will achieve viral suppression, see supra pp. 20-21, reducing the overall spread of the epidemic. 3. Reversal of the judgment below would undermine the Nation’s ability to address future epidemics and other emerging public health threats The example of HIV demonstrates the important role that expanded health insurance plays in the Na- tion’s ability to resist and fight epidemics and other emerging public health threats. Insufficient insurance access detrimentally affects public health on a societal level because communities nationwide divert re- sources from public health programs to cover the ° of course, other factors—such as income levels, baseline in- surance access, and number of physicians per capita—will produce variance in the rate at which each State wil! be able to provide treatment to newly insured people living with HIV. See Sommers et al., 160 Annals of Internal Med. at 592. Even accounting for such variables, however, the evidence demonstrates that health insurance improves outcomes and reduces the epidemic’s spread. See Snider et al., 33 Health Affairs at 391. 28 health care costs of the uninsured. Recent experienc- es with the Ebola virus exposed the threat that emerging diseases pose to the U.S. public health sys- tem, and a recent study found that half of States are unprepared to cope with outbreaks of severe infec- tious diseases. See Levi et al., Outbreaks: Protecting America From Infectious Diseases 16 (Dec. 2014) (25 States and the District of Columbia scored five or low- er out of ten indicators related to preventing, detect- ing, diagnosing and responding to serious infectious disease threats). By reducing overall insurance levels, reversal of the judgment below would not only under- mine nationwide efforts to eradicate ongoing epidem- ics like HIV, but also threaten the ability to respond to future public health threats such as pandemic flu, tuberculosis, measles, or bioterrorism. Prior to the ACA, the Institute of Medicine found that insufficient insurance access had an adverse spillo- ver effect on public health that reached even the in- sured population. Institute of Medicine, America’s Un- insured Crisis at 91-95; Institute of Medicine, A Shared Destiny: Community Effects of Uninsurance (2003). Insufficient insurance access adversely affected State and local public health programs because they devoted resources to uninsured residents that were reallocated from population-based health programs supporting dis- ease surveillance and community-wide health interven- tions. Institute of Medicine, A Shared Destiny at 144. This diversion of resources weakened the ability of health departments to respond to emerging public health threats and ongoing illnesses like the HIV epi- demic. Jd. at 13. Communities with high rates of unin- sured individuals also had insufficient health care deliv- ery capacity, reduced access to emergency medical ser- vices, and fewer available clinical specialists. Institute 29 of Medicine, America’s Uninsured Crisis at 91-95. Ac- cordingly, the Institute of Medicine recommended that the President work with Congress to achieve health insurance coverage for all Americans “as quickly as possible.” Jd. at 114. The President and Congress responded with the ACA, which expanded access to the private health in- surance market with the help of federal subsidies. A successful response to an infectious disease threat re- quires that sick people have unimpeded access to the health care system so that infected individuals do not delay seeking treatment, diseases are recognized quick- ly, and the risk of spreading the disease within the community is minimized. Lurie, H1N1 Influenza, Pub- lic Health Preparedness, and Health Care Reform, 361 New Eng. J. Med. 843, 844 (2009). By increasing access to routine and emergency medical care, the ACA ena- bles earlier detection, treatment, and control of new diseases. Jd.; Reeve et al., The Impacts of the Afforda- ble Care Act on Preparedness Resources and Pro- grams: Workshop Summary 8-9 (2014). A successful response to an infectious disease threat also requires community resilience, which is the ability of a healthy community to withstand and recov- er from a public health emergency. See Vinter et al., Public Health Preparedness in a Reforming Health System, 4 Harv. L. & Pol’y Rev. 339, 339-340 (2010). Again, Congress improved community resilience through the ACA: Increased health insurance access ensures that individuals regularly receive needed care and reduces population levels of chronic diseases and vaccine-preventable illnesses, so that fewer people will suffer from already compromised health in the event of a public health emergency. Lurie, 361 New Eng. J. Med. at 844; Vintner et al., 4 Harv. L. & Pol’y Rev. at 344. 30 The availability of subsidies in all States has ena- bled significant coverage gains among previously unin- sured households and improved access to the health care system for all Americans. See supra pp. 5-12. As communities become healthier nationwide, the Nation will be better able to cope with ongoing epidemics such as HIV and emerging public health threats such as the Ebola virus or a future flu outbreak. Petitioners’ de- sired toppling of the ACA’s statutory scheme in a ma- jority of States, however, would negate all gains in these States and stymie national efforts to promote public health security, threatening the entire popula- tion, both insured and uninsured. CONCLUSION The judgment of the court of appeals should be af- firmed. Respectfully submitted. MARK C. FLEMING Counsel of Record RICHARD A. JOHNSTON RACHEL L. GARGIULO WILMER CUTLER PICKERING HALE AND DORR LLP 60 State Street Boston, MA 02109 (617) 526-6000 mark fleming@wilmerhale.com JANUARY 2015 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40385016_0338%3A40. Public record. Not legal advice.