1. The Patient Protection and Affordability Act (ACA): Legal Challenges and Lessons Learned To Sustain Health Care Reform Mary P. Kivlighan, J.D., M.A.P.A.

2. Overarching goal Provide access to health care for all; and Eliminate health disparities

3. In sum… The ACA closes a gap in access to quality health care using powers granted to the Congress through the U.S. Constitution to regulate the health care markets. Legally, this creates tension between State’s rights and the federal government.

4. Four dimensions of the ACA Policy Political Legal Public Health* * Lawrence Gostin, 2012

5. The Public Health Dimension Organizational reforms Funding Insurance Infrastructure

6. The Legal Dimension – Anti Injunction Act – Individual Mandate – Severability – Medicaid Expansion

7. Anti Injunction Act What is this? How does this implicate the Affordable Care Act?

8. The Individual Mandate Commerce clause Necessary and Proper clause Tax and spending powers

9. Severability of the Individual Mandate Guarantee-issues, community rating and individual mandate The issues: 1. Have these provisions been legitimately enacted? 2. Are these closely allied?

10. Medicaid expansion provision Argument before the court Is the voluntary nature genuine or is it coercive? Does coercion matter?

11. Lessons Learned Sustain the support and imagination of stakeholders through: Extension Academic partners Grassroots coalitions Evidence based policy

12. Design infrastructure that engages these stakeholders Stakeholder commissions and council: Health Benefit Exchanges Health Information Exchanges Accountable Care Organization (ACO)

13. The Public Health Dimension Organizational reforms Funding Insurance Infrastructure