In response to enactment of the ACA, Florida and 25 other states, the National Federation of Independent Business, and other interested parties filed suit challenging the constitutionality of the health insurance coverage requirement (“individual mandate”) and the Medicaid expansion, questions that were ultimately appealed to the U.S. Supreme Court. The Court heard oral arguments pertaining to the case in late March 2012 and issued its ruling upholding the insurance coverage requirement on June 28, 2012, finding that Congress has the authority to levy a tax on individuals who choose to forgo such coverage. With respect to the Medicaid expansion provision, the Court ruled that “Congress is not free … to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding” but that “[n]othing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of health care, and requiring that States accepting such funds comply with the conditions on their use.”5

In practice, the Court ruling makes it optional for the states to adopt the Medicaid expansion provision. Although some states already have taken steps to expand Medicaid before 2014 (as permitted by the ACA), other states, in the wake of the Supreme Court ruling, may choose not to do so at all. A compilation of statements by lawmakers, press releases, and media coverage indicates that as of September 12, 2012, 12 states and the District of Columbia had opted to expand Medicaid and 6 states had elected not to do so (Daily Briefing, 2012).

The six states identified as not participating in Medicaid expansion under the ACA had uninsurance rates above the national average of 44 percent for adults 19 to 64 years of age with incomes less than 139 percent of the FPL in 2010 (KFF, 2012e). One of the concerns raised by the variation in state adoption of Medicaid expansion is the potential lack of health coverage options for individuals who remain ineligible for Medicaid in states that opt out of Medicaid expansion but who have incomes below the level of eligibility for federal subsidies to purchase insurance coverage through the state exchanges (KFF, 2012a).

Despite the uncertainty surrounding what states ultimately might do, a number of the ACA’s provisions are expected to improve access to health care coverage not only for people living with HIV, but also for individuals living with other chronic medical conditions, such as diabetes, hypertension, rheumatoid arthritis, and the like. Several of these provisions have


service capacity at community health centers, including federally qualified health centers, which are an important source of care for people living with HIV who are less able to access traditional sources of medical care.

5National Federation of Independent Business v. Sebelius, 567 U.S. ___ (2012), 55, slip opinion.

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