WASHINGTON, D.C. — Tribal health advocates are breathing a sigh of relief after the nation’s highest court rejected another Republican challenge to the Affordable Care Act.

The landmark law, also known as the ACA, was enacted over a decade ago. It permanently reauthorized the Indian Health Care Improvement Act (IHCIA), ensuring that tribes and their citizens can continue to receive services promised through the trust and treaty obligations of the United States.

But a Republican-led lawsuit had tribes worried that they would have to go back to Congress all over again, leaving their communities in limbo as they battled the COVID-19 pandemic. Those fears were resolved last Thursday, when the U.S. Supreme Court finally put an end to the legal challenge.

“The National Indian Health Board is pleased with the Supreme Court’s decision to protect the Affordable Care Act, which also secures the Indian Health Care Improvement Act, a primary legal foundation and the framework for the entire American Indian and Alaska Native health system,” NIHB Chairman William Smith said in a news release on Friday.

“The ACA and IHCIA offers American Indians and Alaska Natives new and viable options for health coverage, and that coverage brings peace of mind and added security of knowing that the poorly funded Indian Health Service system is bolstered. If our people need specialty care, then they can get it,” added Smith, who also serves as vice president of the Valdez Native Tribe, based in Alaska.

“It is a giant step away from rationing health care and provides the opportunity for our people to get the care they need when they need it,” Smith said, stressing the importance of the permanent reauthorization of the ICHIA.

The vote in the case 7 to 2, with even the more conservative-leaning members of the Supreme Court agreeing to turn back the GOP challenge. Justice Stephen G. Breyer wrote the majority opinion, holding that the states lacked legal standing to bring the lawsuit in the first place.

“We proceed no further than standing,” Breyer, who was nominated to the bench by Democratic former president Bill Clinton, wrote in the 16-page opinion.

“Neither the individual nor the state plaintiffs have shown that the injury they will suffer or have suffered is ‘fairly traceable’ to the ‘allegedly unlawful conduct’ of which they complain,” Breyer continued in a decision joined by justices nominated by Democratic and Republican presidents alike.

But two conservative-leaning justices — including a surprising voice — took another view of the dispute. In a dissent that was twice as long as the majority opinion, they argued that their colleagues “pulled off an improbable rescue” for the ACA for the third time since it became law in 2010.

Justice Samuel Alito, who wrote the dissent, went so far as to compare the GOP lawsuit to a landmark treaty rights victory secured by the Mille Lacs Band of Ojibwe. Since the tribe was able to pursue the matter in federal court, he reasoned that the state governments should be able to do the same.

“In other words, the bands obtained relief with the same type of argument the state plaintiffs press here,” Alito argued in a dissent joined by Justice Neil Gorsuch, whose knowledge of Indian law is unprecedented in Supreme Court history and who has consistently sided with tribal interests over the last four years.

Republicans have been trying to dismantle, undermine and invalidate the ACA ever since it was signed by Democratic former president Barack Obama in March 2010. GOP lawmakers tried to repeal the law in Congress but when that failed, the attorney general of Texas turned to the federal court system, lodging the case before a relatively inexperienced judge who struck down the statute as unconstitutional.

The same federal judge in Texas, incidentally, invalidated the Indian Child Welfare Act in response to a lawsuit filed by the same Republican attorney general of Texas, Ken Paxton. The outcome led to an extremely-lengthy and complicated set of rulings from the same appeals court that handled the ACA case.

But with the health care dispute resolved by the Supreme Court, tribes and their advocates have one less controversy to worry about.

“It was a victory 11 years ago when President Obama signed the ACA into law and this decision renews that triumph,” said Stacy Bohlen, a citizen of the Sault Ste. Marie Tribe of Chippewa Indians who serves as chief executive officer of the NIHB. “With this decision, the highest court secured access to health coverage for American Indian and Alaska Native people and all Americans.”

The IHCIA first became law in 1976, just as the era of self-determination was taking hold. Congress easily renewed the law four times after that and was well on its way to a fifth reauthorization until Republican George W. Bush became president in 2001.

With cooperation from key Republican lawmakers, Bush and his administration repeatedly prevented the IHCIA from advancing in Congress throughout the eight years of his presidency. Everything changed after Obama came on board in 2009 and Democrats gained control of the legislative branch.

“When I heard the Supreme Court’s decision on the news, I was just elated, I wanted to cry,” said Rachel Joseph, a citizen of the Lone Pine Paiute-Shoshone Tribe who was a leader of the IHCIA effort during those rocky years.

“I thought about all the Americans who will continue to have health coverage, especially those with pre-existing conditions,” Joseph said in the NIHB news release.

“It was a feeling of happiness and gratitude because we spent many long hours during the Bush years to get broader authorizations of the Indian Health Care Improvement Act and more opportunities for tribes to expand care,” added Joseph, who previously served as chair and vice chair at Lone Pine. “We refused to go backwards, and we put a lot of heart and soul into that work.”

President Joe Biden, who served as vice president under Obama, praised the Supreme Court decision as well. His administration has sought to boost the historically-underfunded Indian Health Service as tribes continue to address the disproportionate impacts of COVID-19 in their communities.

“After more than a decade of attacks on the Affordable Care Act through the Congress and the courts, today’s decision — the third major challenge to the law that the U.S. Supreme Court has rejected — it is time move forward and keep building on this landmark law,” Biden said in a statement last Thursday.

Although the federal government was the target of the lawsuit, the case that went before the Supreme Court was known as known primarily as California v. Texas. California took a lead role in the dispute, as its Democratic former attorney general Xavier Becerra stepped up to defend the ACA and the IHCIA.

Becerra, who also defended ICWA from attacks by Texas and other states, now serves as Secretary of Health and Human Services in Biden’s administration. In that role, he oversees the IHS, which is responsible for providing care to 2.6 million American Indians and Alaska Natives in 37 states.

“As a member of Congress, I helped draft and pass the ACA. As the Attorney General of California, I took this case all the way to the Supreme Court,” Becerra said in a statement. “And now, as Secretary, I will continue to stand up and stand with you to protect access to affordable health care.”

Syllabus | Opinion [Breyer] | Concurrence [Thomas] | Dissent [Alito] | Full Document

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