The Affordable Care Act (ACA); Provision prohibiting insurers from discriminating against healthcare providers; Standing; Causation based on lack of regulation causing third-party reactions; Distinguishing Diamond Alternative Energy, LLC v EPA; Redressability; Department of Health & Human Services (HHS)

The court held that plaintiff-American Association of Nurse Anesthesiology lacked standing to seek a writ of mandamus compelling defendants-HHS and HHS Secretary to enforce the ACA’s provision prohibiting insurers from discriminating against healthcare providers. Plaintiff alleged private insurers were violating the ACA “by paying nurse anesthetists less than physician anesthesiologists who provide the same services.” The district court granted defendants’ motion to dismiss based on lack of standing. On appeal, the court concluded that even assuming plaintiff “properly established an injury in fact, its members can’t show that any injury they experienced was fairly traceable to the defendants’ conduct and redressable by a favorable judgment.” Thus, they lacked standing. As to causation, plaintiff alleged “its members experienced the injury of lower reimbursement rates for independent anesthesia services. But HHS didn’t impose those rates—private insurers did. The Association theorizes that HHS nonetheless caused its injury because those insurers are ‘[e]mboldened by the government’s’ failure to enforce the ACA’s nondiscrimination provision. That causal relationship is too speculative to support standing.” The court added that, even “assuming that government inaction caused its members’ injuries, the Association doesn’t explain why the defendants’ inaction in particular did so.” It noted that the “states have primary enforcement authority over the ACA’s nondiscrimination provision.” Citing Diamond, plaintiff argued that it had “standing because the third-party insurers ‘likely react’ to HHS’s inaction ‘in predictable ways that . . . likely cause’ its members’ injuries.” But the court found that this was a “far different” case than Diamond. Given that “insurers didn’t implement the challenged policies for over a decade after the alleged nonenforcement started, the Association hasn’t shown that an insurer would ‘likely react’ to HHS’s inaction by cutting reimbursements for its members. At bottom, the Association can’t trace its members’ injuries to the Secretary and HHS.” The court further concluded that no member of plaintiff could “show that his injury is likely redressable by a favorable outcome in this” case. Affirmed.