Case name: David King, et al, v. Sylvia Burwell, Secretary of Health and Human Services, et al.
Case number: 14-114 (link to decision)
Date decided: June 25, 2015
Issue: Interpretation of statute – Section 36B of the Internal Revenue Code 
Background: The Patient Protection and Affordable Care Act (ACA) introduced a set of rules to provide health insurance. Among them were these:
Health insurance providers must accept every individual who applies for coverage.Individuals are required to maintain health insurance; failure to do so will cause a penalty to be imposed. This requirement does not apply if the cost of insurance exceeds eight percent of income.
States are required to establish exchanges, so that their citizens can choose among alternative health plans. If a state does not establish an exchange, the Department of Health and Human Services (HHS) will set one up in its place.
A credit is available in the form of subsidies to assist in paying the premiums for taxpayers who have enrolled in an insurance plan through “an Exchange established by the State under [42 U.S.C. Section 18031]”. 
[Pages 4-5 of the Court’s opinion.]
In 2012, the Internal Revenue Service (IRS) published a rule that interpreted the ACA to allow tax credits to individuals enrolled through both the state and the federal exchanges. [Page 6.]
David King and the other petitioners are residents of Virginia who claim that the cost of buying health insurance exceeded eight percent of their income, and thus were not required to purchase it. HHS contended that with the tax credits, their cost of health insurance was below the eight percent threshold, and thus the requirement applied. Virginia was not a state that established its own exchange, and the petitioners contended that the credits were not available to them because the ACA limited the credit to individuals paying premiums through an “exchange established by the state”.
The question before the Court was whether the ACA provided credits to individuals enrolled through only the state exchanges, or whether the ACA provided credits to individuals enrolled through either a state exchange or the federal exchange.
THE COURT’S OPINION
Chief Justice Roberts (joined by Justices Kennedy, Ginsburg, Breyer, Sotomayor, and Kagan) opens the Court’s opinion with a description of previous attempts at health insurance reform, and the “death spiral”. States would require insurers to accept anyone who applied, but without a requirement that citizens purchase insurance, “they encouraged people to wait until they got sick to buy insurance.” [Page 2.] If individuals aren’t paying premiums until they are sick, and if the insurer is required to accept their application for insurance, costs will go up. As the Court put it on page 2 of its opinion:
Insurers were forced to increase premiums to account for the fact that, more and more, it was the sick rather than the healthy who were buying insurance. And that consequence fed back into the first: As the cost of insurance rose, even more people waited until they became ill to buy it.[Page 2.]
The Court points out that it wasn’t until states (in particular, Massachusetts) began requiring individuals to buy health insurance that the death spiral was prevented.
All of this may not seem crucial to the statutory interpretation, but the Court invokes this as foreshadowing to make its bases for upholding the tax credits.
Before turning to the statutory analysis, the Court discusses the standard of review it is going to engage in. Under the “Chevron” rule, the Court normally conducts a two-step inquiry when interpreting statutes: 1) Is the statute ambiguous? If so, then 2) the agency (in this case, the IRS) will be given deference. The theory behind this is that the ambiguity is an implicit delegation to the government agency to fill in the holes. However, as the Court notes, “[i]n extraordinary cases, however, there may be reason to hesitate before concluding Congress has intended such an implicit delegation”. [Page 8.] The Court then declares that this is one of those extraordinary cases, and proceeds to deliver its own interpretation of the statute. 
Here is the relevant text of the premium tax credit in the Internal Revenue Code:
26 U.S. Code § 36B – Refundable credit for coverage under a qualified health plan(a) In general. In the case of an applicable taxpayer, there shall be allowed as a credit against the tax imposed by this subtitle for any taxable year an amount equal to the premium assistance credit amount of the taxpayer for the taxable year.
(b) Premium assistance credit amount. For purposes of this section—
(1) In general. The term “premium assistance credit amount” means, with respect to any taxable year, the sum of the premium assistance amounts determined under paragraph (2) with respect to all coverage months of the taxpayer occurring during the taxable year.(2) Premium assistance amount. The premium assistance amount determined under this subsection with respect to any coverage month is the amount equal to the lesser of—
(A) the monthly premiums for such month for 1 or more qualified health plans offered in the individual market within a State which cover the taxpayer, the taxpayer’s spouse, or any dependent (as defined in section 152) of the taxpayer and which were enrolled in through an Exchange established by the State under [42 U.S.C. Section 18031], or(B) the excess (if any) of—
(i) the adjusted monthly premium for such month for the applicable second lowest cost silver plan with respect to the taxpayer, over
(ii) an amount equal to 1/12 of the product of the applicable percentage and the taxpayer’s household income for the taxable year. 
How the Court interprets Section 36B
Starting on Page 9, the Court breaks down the statute into three elements to receive the credit: the individual must enroll in an insurance plan through “an Exchange”; the Exchange must be one that is “established by the State”; finally, the Exchange must be one that is established “under [42 U.S.C. Section 18031]”. Here is the Court’s analysis of each of the elements:
1. The individual must enroll in an insurance plan through “an Exchange”. The Court begins by comparing two statutory provisions:
(1) In general. Each State shall . . . establish an American Health Benefit Exchange . . . for the State. . . .
(1) In general. If—
(A) a State is not an electing State under subsection (b); or(B) the Secretary determines, on or before January 1, 2013, that an electing State—
(i) will not have any required Exchange operational by January 1, 2014 . . .the Secretary shall . . . establish and operate such Exchange within the State and the Secretary shall take such actions as are necessary to implement such other requirements.
The Court interprets these two statutes together to mean the Federal Exchange is, for all intents and purposes, equivalent to the State Exchange:
By using the phrase “such exchange“, Section 18041 instructs the Secretary to establish and operate the same Exchange that the State was directed to establish under Section 18031. . . . In other words, State Exchanges and Federal Exchanges are equivalent — they must meet the same requirements, perform the same functions, and serve the same purposes. Although State and Federal Exchanges are established by different sovereigns, Sections 18031 and 18041 do not suggest that they differ in any meaningful way. A Federal Exchange therefore counts as “an Exchange” under Section 36B.[Page 10. Emphasis in the original.]
2. The Exchange must be “established by the State”. To address this requirement, the Court then looked to two more statutes from the ACA:
(A) In general. An Exchange shall make available qualified health plans to qualified individuals and qualified employers.42 U.S.C. Section 18032(f)(1)(A):
(1) Qualified individuals. In this title:(A) In generalThe term “qualified individual” means, with respect to an Exchange, an individual who—
(i) is seeking to enroll in a qualified health plan in the individual market offered through the Exchange; and
(ii) resides in the State that established the Exchange.
The Court examines a chain of logic in interpreting these statutes and finds a problem:
The requirement in Section 18031(d)(2)(A) to make insurance plans available to qualified individuals applies to all exchanges, both state and federal.“Qualified individual” means only individuals residing in States that establish an Exchange.
Unless a State establishes an Exchange, there are no “qualified individuals” for which the Federal exchange to provide its Exchange of insurance plans.
Faced with this apparent absurdity, the Court cites this as evidence that the phrase “established by the State” may not always be used in its natural meaning. [Pages 10-11.]
3. The Exchange must be one that is established “under [42 U.S.C. Section 18031]”.
Continuing with the statutory dissection:
(d) Other definitions
(21) Exchange. The term “Exchange” means an American Health Benefit Exchange established under section 18031 of this title.
The Court then substituted this definition for the use of the term at the end of the 18041 excerpt above:
the Secretary shall . . . establish and operate such [American Health Benefit Exchange established under section 18031 of this title] within the State and the Secretary shall take such actions as are necessary to implement such other requirements
The Court viewed this as an anomaly, appearing to allow Federal Exchanges to be established under not only the conditions of Section 18041 (when States do not set up an exchange), but also under Section 18031 itself. Otherwise, the Court said, “the Federal Exchange, by definition, would not be an ‘Exchange’ at all”.
What does this analysis prove to the Court? Ambiguity as to the meaning of the term “an Exchange established by the State under [42 U.S.C. 18031]. The Court cites other requirements of both State and Federal Exchanges (advertising the credits to the community, setting up a calculator to determine the true cost to the customer, reporting requirements to the Treasury Secretary). The Court reasons that if the credits weren’t available to the Federal Exchanges, why were they required to engage in all of this activity related to the credits? [Pages 13-14.]
The Purpose Of the ACA
Having freed itself from the shackles of the text, the Court bases its decision by determining the “broader structure” of the Act to interpret the tax credits under Section 36B, and recites a list of reasons why the credits should be available in the Federal Exchanges:
- If the credits aren’t available, it would destabilize the individual insurance market.If the credits aren’t available, the result would negate its own stated purpose.
- If the credits aren’t available, only a small segment of individuals would be able to afford to purchase the insurance. This would drive up the costs, resulting in higher prices, fewer and more expensive customers, and another increase in costs. The death spiral would return.
- It would be “implausible” that Congress intended to impose a coverage requirement without making the credits available.
The Court holds that the credits described in Section 36B apply to all health insurance Exchanges, State and Federal.
Justice Scalia, joined by Justices Thomas and Alito, opens the dissent by stating what to the non-lawyer public would appear to be obvious:
The Court holds that when the Patient Protection and Affordable Care Act says “Exchange established by the State” it means “Exchange established by the State or the Federal Government.” That is of course quite absurd, and the Court’s 21 pages of explanation makes it no less so.The dissent agrees with the Court on the principle that a statute must be interpreted in its context, but it accuses the Court of using rules of context not to understand the ACA, but rewrite it.
It then points out a series of specific reasons why the statutes for the State Exchange and for the Federal Exchange should be interpreted as separate creations:
“State”, for purposes of these statutes, has an explicit definition: “each of the 50 states and the District of Columbia.” The Secretary of Health and Human Services is not one of these.
The State Exchange and the Federal Exchange have distinct statutory origins. The creation, the funding, and the scope of their authority for each comes from different statutory provisions. The dissent then says “[p]rovisions such as these destroy any pretense that a Federal Exchange is in some sense also established by a State.” [Page 4.]
In addition to the tax credit provisions here, the dissent points out other examples where the tax credits are connected to an “Exchange established by the State”. (The statutes cited are in Appendix A.) These references, the dissent says, are not empty citations, and Congress made distinctions between this term and the more generic term “Exchange”. To interpret these terms interchangeably removes the limitation that the words “by the State” was intended to provide.
Apart from the linguistic problems of the Court’s interpretation, the dissent states that the practical effects of the Court’s interpretation make “nonsense“ of the statute. When the ACA instructs the states to use a secure user interface to calculate the customer’s credits, or to control contracting decisions in setting up the Exchanges, the dissent asks “[w]hy would a State get to control the contracting decisions of a Federal Exchange?” [Page 7.] The Court attempted to limit the applicability of this switch in definition to only the tax credits, which highlights the oddity of its rules of interpretation on the eligibility of the credit..
The ACA says that if a territory (i.e., Guam, Puerto Rico, etc.) creates an Exchange, it will be treated as a State for certain purposes, which indicates that Congress knew how to write legislation treating other Exchanges as equivalent to State Exchanges. The ACA does not make any similar allowance for the Federal government.
The dissent next addresses the Court’s bases for its decision:
Section 36B states that if a State did not set up an Exchange, the federal government was required to establish “such Exchange” in its place. The Court interpreted this to mean that the Federal and State Exchanges are the same. The dissent points out that this runs counter to proper interpretation rules:
The Court’s argument also overlooks the rudimentary principle that a specific provision governs a general one. Even if it were true that the term “such Exchange” in §18041(c) implies that federal and state Exchanges are the same in general, the term “established by the State” in §36B makes plain that they differ when it comes to tax credits in particular.The Advertising Campaign, the Benefits Calculator, and the Reporting Requirement
In the ACA, both State and Federal Exchanges were instructed to advertise the tax credits, provide a calculator to determine the credit amount, and to report on how much of credit was authorized. The Court cited this as evidence that Congress intended individuals to receive tax credits through the Federal Exchanges. Why else would they be required to do these things otherwise? The dissent states that the Court is making too much of these distinctions:
Even if that observation were true, it would show only oddity, not ambiguity. Laws often include unusual or mismatched provisions. The Affordable Care Act spans 900 pages; it would be amazingif its provisions all lined up perfectly with each other.This Court “does not revise legislation . . . just because the text as written creates an apparent anomaly.”
The ACA defined a “qualified individual” as someone living in the “State that established the Exchange”. The Court says that, given its most natural interpretation, this would exclude anyone from “qualified individual” status in a Federal Exchange, and would thus make null the mandate to establish the Federal Exchange.
The dissent uses an analogy to point out the problem with this interpretation:
Imagine that a university sends around a bulletin reminding every professor to take the “interests of graduate students” into account when setting office hours, but that some professors teach only undergraduates. Would anybody reason that the bulletin implicitly presupposes that every professor has “graduate students,” so that “graduate students” must really mean “graduate or undergraduate students”? Surely not. Just as one naturally reads instructions about graduate students to be inapplicable to the extent a particular professor has no such students, so too would one naturally read instructions about qualified individuals to be inapplicable to the extent a particular Exchange has no such individuals.
In Subsection 36B(a), the credit does not have anything limiting the range of taxpayers eligible for the credit. Subsection (b) gives a formula for the amount of the credit, which is the lesser of the amount of premiums paid through an “Exchange established by the State” or the difference between the cost of a certain government plan and the taxpayer’s required contribution. There’s more on how this credit works in Appendix B, but the point here is that the Court found it strange that in a natural reading of the statute would make those in the Federal Exchange eligible for the credit, but the only amount their credit could be would be zero. The dissent points out that this type of legislating is common in the tax code, and should not be used as a basis for redefining how the credit works.
(My two cents: from my background in tax law, I can provide an important distinction that the Internal Revenue Code does not directly tax individuals. It can’t, without great difficulty, do that. Instead, the Code imposes a tax on the income of individuals, which includes mechanisms to reduce a tax credit or deduction, sometimes to zero.)
The Design and Purpose of the ACA
The Court had cited three major health reforms: insurers must accept requests for individual coverage, individuals must maintain coverage, and tax credits are made available to assist in the cost. The Court reasoned that because the first two reforms applied nationally, the third must do so as well. The dissent addresses this accordingly:
Section 36B has no ambiguity to justify this analysis, reciting a summary of the previous analysis.The analysis itself is faulty: if Congress wrote that the express terms of the ACA make only two of the three reforms, that is perfectly reasonable for them to do so. What about the danger of the destabilization and death spirals in the insurance market? The dissent says that all this proves is that the statute has a flaw, not that it justifies rewriting it to mean the opposite of its clear meaning.
This section is not the only place where Congress experimented with mixing combinations of reforms. Citing a proposed-but-rejected plan to require insurers to accept long-term care coverage requests, but with no mandate for individuals to maintain it, the dissent asks this question:
How could the Court say that Congress would never dream of combining guaranteed-issue and community-rating requirements with a narrow individual mandate, when it combined those requirements with no individual mandate in the context of long-term care insurance?Like the analysis of the wording, the purpose of the statute cannot be taken in isolation. One of the purposes of the ACA was to encourage state participation, for which the offering of tax credits for a state setting up its own exchange was an incentive. By interpreting the credit to apply to all exchanges, the Court’s opinion runs against that purpose.
The dissent closes with a discussion over the power of the Supreme Court to correct “in artful drafting”, and when correcting a “patently obvious” drafting mistake crosses over to rewriting the substance of the law:
Rather than rewriting the law under the pretense of interpreting it, the Court should have left it to Congress to decide what to do about the Act’s limitation of tax credits to state Exchanges. If Congress values above everything else the Act’s applicability across the country, it could make tax credits available in every Exchange. If it prizes state involvement in the Act’s implementation, it could continue to limit tax credits to state Exchanges while taking other steps to mitigate the economic consequences predicted by the Court. If Congress wants to accommodate both goals, it could make tax credits available everywhere while offering new incentives for States to set up their own Exchanges. And if Congress thinks that the present design of the Act works well enough, it could do nothing. Congress could also do something else altogether, entirely abandoning the structure of the Affordable Care Act. The Court’s insistence on making a choice that should be made by Congress both aggrandizes judicial power and encourages congressional lassitude.
Finally, the dissent laments the legacy of this decision and the Court’s previous decision holding that the penalty for not purchasing life insurance was a tax, not a penalty:
Perhaps the Patient Protection and Affordable Care Actwill attain the enduring status of the Social Security Act or the Taft-Hartley Act; perhaps not. But this Court’s two decisions on the Act will surely be remembered through the years. The somersaults of statutory interpretation they have performed (“penalty” means tax, “further [Medicaid] payments to the State” means only incremental Medicaid payments to the State, “established by the State”means not established by the State) will be cited by litigants endlessly, to the confusion of honest jurisprudence.And the cases will publish forever the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takesto uphold and assist its favorites.
 Title 26, Section 36B of the United States Code (U.S.C.)
 Section 1311 of the ACA was codified as 42 U.S.C. Section 18031.
 In the Texas Department of Housing and Community Affairs decision, also issued this day, the Court similarly declined to give the federal agency’s regulation any weight in its decision, even though both decisions were consistent with the position expressed in the regulations.
 There’s more to this statute (link here). However, this remaining portion of the statute involves the mechanics of how the credit is calculated and the definitions of who is eligible. It doesn’t involve the questions before the Court in this decision.
APPENDIX A: LIST OF STATUTES REFERRED TO BY THE DISSENT THAT ASSUME A LINK BETWEEN THE PREMIUM TAX CREDIT AND AN “EXCHANGE ESTABLISHED BY THE STATE”
These statutes are from Pages 5-6 of the dissent. The bold italicized emphasis is mine.
(b) Enrollment simplification and coordination with State health insurance exchanges and CHIP
(1) In general A State shall establish procedures for—[ . . . ]
(B) enrolling, without any further determination by the State and through such website, individuals who are identified by an Exchange established by the State under section 18031 of this title as being eligible for—
(i) medical assistance under the State plan or under a waiver of the plan; or
(ii) child health assistance under the State child health plan under subchapter XXI;
(C) ensuring that individuals who apply for but are determined to be ineligible for medical assistance under the State plan or a waiver or ineligible for child health assistance under the State child health plan under subchapter XXI, are screened for eligibility for enrollment in qualified health plans offered through such an Exchange and, if applicable, premium assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 (and, if applicable, advance payment of such assistance under section 18082 of this title), and, if eligible, enrolled in such a plan without having to submit an additional or separate application, and that such individuals receive information regarding reduced cost-sharing for eligible individuals under section 18071 of this title, and any other assistance or subsidies available for coverage obtained through the Exchange;
(D) ensuring that the State agency responsible for administering the State plan under this subchapter (in this section referred to as the “State Medicaid agency”), the State agency responsible for administering the State child health plan under subchapter XXI (in this section referred to as the “State CHIP agency”) and an Exchange established by the State under section 18031 of this title utilize a secure electronic interface sufficient to allow for a determination of an individual’s eligibility for such medical assistance, child health assistance, or premium assistance, and enrollment in the State plan under this subchapter, subchapter XXI, or a qualified health plan, as appropriate;
[ . . . ]
(2) Agreements with State health insurance exchanges. The State Medicaid agency and the State CHIP agency may enter into an agreement with an Exchange established by the State under section 18031 of this title under which the State Medicaid agency or State CHIP agency may determine whether a State resident is eligible for premium assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 (and, if applicable, advance payment of such assistance under section 18082 of this title), so long as the agreement meets such conditions and requirements as the Secretary of the Treasury may prescribe to reduce administrative costs and the likelihood of eligibility errors and disruptions in coverage.
[ . . . ]
(4) Enrollment website requirements. The procedures established by State under paragraph (1) shall include establishing and having in operation, not later than January 1, 2014, an Internet website that is linked to any website of an Exchange established by the State under section 18031 of this title and to the State CHIP agency (if different from the State Medicaid agency) and allows an individual who is eligible for medical assistance under the State plan or under a waiver of the plan and who is eligible to receive premium credit assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 to compare the benefits, premiums, and cost-sharing applicable to the individual under the State plan or waiver with the benefits, premiums, and cost-sharing available to the individual under a qualified health plan offered through such an Exchange, including, in the case of a child, the coverage that would be provided for the child through the State plan or waiver with the coverage that would be provided to the child through enrollment in family coverage under that plan and as supplemental coverage by the State under the State plan or waiver.
(d) Maintenance of effort
(3) Continuation of eligibility standards for children until October 1, 2019(B) Assurance of exchange coverage for targeted low-income children unable to be provided child health assistance as a result of funding shortfallsIn the event that allotments provided under section 1397dd of this title are insufficient to provide coverage to all children who are eligible to be targeted low-income children under the State child health plan under this subchapter, a State shall establish procedures to ensure that such children are screened for eligibility for medical assistance under the State plan under subchapter XIX or a waiver of that plan and, if found eligible, enrolled in such plan or a waiver. In the case of such children who, as a result of such screening, are determined to not be eligible for medical assistance under the State plan or a waiver under subchapter XIX, the State shall establish procedures to ensure that the children are enrolled in a qualified health plan that has been certified by the Secretary under subparagraph (C) and is offered through an Exchange established by the State under section 18031 of this title. For purposes of eligibility for premium assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 and reduced cost-sharing under section 18071 of this title, children described in the preceding sentence shall be deemed to be ineligible for coverage under the State child health plan.
APPENDIX B: HOW DO THESE CREDITS WORK IN REAL LIFE?
The 2014 tax year was the first one in which the Federal tax credits went into effect. The process goes like this:
As a part of signing up for a health insurance plan, the customer provides estimated income information for the year. Based on this information, and by a formula set up in the ACA, part of the monthly premiums will be a credit paid by the government.At the end of the year, a Form 1095-A is sent to the customer.
Form 1095-A (apologies for the graininess)
This is issued by the Federal Exchange to report the activity during the year. For these purposes, the important part is in Part III:
For each month in which the customer was covered under the Exchange-provided plan, the amount paid out of pocket is entered in Column A. Column B is a fixed amount – the monthly cost of one of the plans offered by the government (the “second lowest cost silver plan“). Column C – the Monthly Advance Payment – is the monthly amount paid on the customer’s behalf, which is computed based on the income information provided. Whether or not the advance payment was too much or too little will be determined when the federal tax return is prepared after the end of the year.The information from the Form 1095-A is used by the individual to complete a Form 8962, which determines whether the monthly credits during the year were too much or too little, based on the actual income during the year.
Form 8962, Part 1
Part 1 computes the portion of the health insurance premium that is deemed to be the individual’s required contribution to the monthly health insurance premiums. To use an example, assume there are three members of the family (a married couple with one child) and $50,000 of income earned during the year. The Federal Poverty Line is from a table in the instructions, and $50,000 is 256% of the applicable poverty line. The .0822 is also from a table in the instructions, based on the amount of income over the poverty line. The .0822 is multiplied by the income to determine how much the taxpayers are deemed to have contributed toward the health insurance. Another way of putting it is that for a household of three exemptions and income of $50,000, they are supposed to be contributing 8.22% of their income toward health insurance.The amount of the Premium Tax Credit (or, for those who were credited too much during the year, the Excess Premiums Paid Tax) is determined in Part 2:
Under most circumstances, the premium rate will change at some time during the year and Lines 12 through 23 would be used instead of Line 11, but for simplicity’s sake, this example assumes 12 monthly payments of $400 (Column A), a $1,000 per month cost of the second-lowest cost silver plan (SLCSP) from the 1095-A (Column B), and $343 per month of deemed contributions from the taxpayers (Column C). The maximum credit is the $7,890 difference between the deemed taxpayer contribution and the SLCSP (Column D). In this case, the annual premium credit (Column E) is at the maximum of the $4,800 paid. (For this credit, you don’t get a credit for more than what you paid.)
Once the annual premium tax credit is computed, this amount is compared to the assistance received during the year. In this example, the taxpayers paid were entitled to $4,800 of credit ($400 per month), and received $4,320 ($360 per month). The difference of $480 is entered as a credit on the Federal Income Tax Return.