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U.S. Court of Appeals for District of Columbia Rules Insurance Mandate is Constitutional

News outlets are covering the appeals court decision in the Susan Seven-Sky vs. Holder challenge to the health law. The judges split two-to-one, with Reagan and Carter appointees in the majority and a George W. Bush appointee dissenting.

Text of D.C. District Court Opinion Blocking Aetna-Humana Merger

158 pages. "The Court concludes that the proposed merger is likely to substantially lessen competition in Medicare Advantage in all 364 complaint counties and in the public exchanges in the three complaint counties in Florida.... In that market, which is the primary focus of this case, the merger is presumptively unlawful ... In the public exchanges, the Court finds that Aetna withdrew from competing in the 17 complaint counties for 2017 specifically to evade judicial scrutiny of the merger.... The Court finds that Aetna is likely to offer plans on the exchanges only in the three complaint counties in Florida in 2018 and beyond, and that the merger is likely to substantially lessen competition in those counties. And as in the Medicare Advantage market, the Court concludes that defendants' proffered efficiencies do not offset the anticompetitive effects of the merger." [U.S. v. Aetna Inc., No. 16-1494 (D.D.C. Jan. 23, 2017)]

Text of District Court Order Enjoining Merger of Anthem and Cigna (PDF)

12 pages. "[T]he merger will be enjoined due to its likely impact on the market for the sale of health insurance to 'national accounts' ... within the fourteen states where Anthem operates as the Blue Cross Blue Shield licensee.... [P]laintiffs have established that the high level of concentration in this market that would result from the merger is presumptively unlawful under the U.S. Department of Justice and Federal Trade Commission Horizontal Merger Guidelines ... The evidence has also shown that the merger is likely to result in higher prices, and that it will have other anticompetitive effects: it will eliminate the two firms' vigorous competition against each other for national accounts, reduce the number of national carriers available to respond to solicitations in the future, and diminish the prospects for innovation in the market." [U.S. v. Anthem, No. 16-1493 (D. D.C. Feb. 8, 2017)]

Text of District Court Opinion Upholding HHS Requirements for Hospital Price Transparency (PDF)

43 pages. "Where, as here, the goal of the statute is '[b]ringing down the cost of health care coverage,' it is reasonable for the agency to have construed the statute to require the publication of charges that would impact the largest group of patients.... The agency's Rule is exacting, but the demands flow from ... the congressional determination about the role of price transparency in bringing down health care costs and the reality of hospital billing.... By acknowledging conflicting data and articulating which information it found most convincing, the agency fulfilled its duty to examine the evidence before it and connect it to the Final Rule." [The American Hospital Association v. Azar, No. 19-3619 (D.D.C. Jun. 23, 2020)]

Text of Federal District Court Opinion: ERISA Provides No Statutory Penalty for Failure to Provide Plan Guidelines

"The disability durational and claims guidelines that plaintiff requested fall under the ERISA section 1133 regulations because, construing the facts in favor of plaintiff, they were 'relied upon' or at least 'considered ... in the course of making [plaintiff's] benefit determination.' Indeed, that is the very reason plaintiff seeks them.... Nothing in the text of the ERISA statute or regulations indicates that section 1132(c) penalties are available for violations of section 1133 or its regulations, and section 1133 does not provide for penalties." [Marcin v. Reliance Standard Life Insurance Company, No. 13-1308 (D.D.C. June 20, 2014)]

Text of District Court Opinion Enjoining Merger of Anthem and Cigna (PDF)

140 pages. "[T]he merger will be enjoined due to its likely impact on the market for the sale of health insurance to 'national accounts' -- customers with more than 5000 employees, usually spread over at least two states -- within the fourteen states where Anthem operates as the Blue Cross Blue Shield licensee.... This brings us to the elephant in the courtroom. In this case, the Department of Justice is not the only party raising questions about Anthem's characterization of the outcome of the merger: one of the two merging parties is also actively warning against it." [U.S. v. Anthem, No. 16-1493 (D.D.C. Feb. 8, 2017; 12-page order was previously published, this redacted opinion released by the court on Feb. 21, 2017)]

Text of D.C. District Court Opinion: ACA Does Not Permit Cost-Sharing Reduction Payments to Insurers

"Section 1401 [of the ACA] provides tax credits to make insurance premiums more affordable, while Section 1402 reduces deductibles, co-pays, and other means of 'cost sharing' by insurers. Section 1401 was funded by adding it to a preexisting list of permanently-appropriated tax credits and refunds. Section 1402 was not added to that list. The question is whether Section 1402 can nonetheless be funded through the same, permanent appropriation. It cannot.... Such an appropriation cannot be inferred. None of Secretaries' extra-textual arguments -- whether based on economics, 'unintended' results, or legislative history -- is persuasive. The Court will enter judgment in favor of the House of Representatives and enjoin the use of unappropriated monies to fund reimbursements due to insurers under Section 1402. The Court will stay its injunction, however, pending appeal by either or both parties." [U.S. House of Representatives v. Burwell, No. 14-1967 (D.D.C. May 12, 2016)]

Text of D.C. District Court Ruling: ACA Allows Premium Subsidies in States with Federally Run Health Insurance Marketplaces

"Why would Congress have inserted the phrase 'established by the State under [42 U.S.C. 18031]' if it intended to refer to Exchanges created by a state or by HHS? But defendants provide a plausible and persuasive answer: Because the ACA takes a state-established Exchange as a given and directs the Secretary of HHS to establish such Exchange and bring it into operation if the state does not do so. In other words, even where a state does not actually establish an Exchange, the federal government can create 'an Exchange established by the State under [42 U.S.C. 18031]' on behalf of that state." [Halbig v. Sebelius, No. 13-062 (D.D.C. Jan. 15, 2014)]

Text of Federal District Court Case Prohibiting HHS from Imposing $100/Day Penalty on Certain Sales of Fixed Indemnity Health Plans

14 pages. "Plaintiffs ... sell insurance products known as 'fixed indemnity plans' ... [D]efendants issued a rule that bars plaintiffs from selling fixed indemnity plans to individual consumers unless those consumers certify that they have 'minimum essential coverage' under the [ACA].... [T]he Court will grant plaintiffs' motion for a permanent injunction and deny defendants' motion to dismiss for lack of jurisdiction.... [N]o matter what 'fixed indemnity insurance' means at its margins, any attempt to define that phrase [in a regulation] in a way that imports wholly foreign concepts is not an act of definition as this Court understands it." [Central United Life, Inc. v. Burwell, No 14-1954 (D.D.C. Sept. 11, 2015)]

Text of D.C. District Court Opinion: PBGC Must Reconsider Denial of Participant's Lump Sum Benefit (PDF)

"The PBGC argues that the statute is silent as to whether a participant who requests a lump-sum payment before a plan administrator submits a notice of distress termination is entitled to such a payment after the administrator submits the notice, and that its policy (denying payment under such circumstances) rests on a reasonable interpretation of the statute that is consistent with congressional intent.... The problem for the PBGC is that ... while the policy states that requests submitted before the plan administrator submits a notice of distress termination may be denied after the notice is submitted, in this case the request was not only submitted but also denied before the plan administrator submitted its termination notice to the PBGC." [Fisher v. PBGC, No. 14-1275 (D.D.C. Feb. 25, 2016)]