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Alaska Governor Expands Medicaid By Skirting GOP Lawmakers

Jeffrey Young   |   July 16, 2015    2:20 PM ET

WASHINGTON -- Alaska would become the latest state to sign on to a major expansion of Medicaid under the Affordable Care Act through a plan announced by Gov. Bill Walker on Thursday.

Walker, a Republican-turned-independent elected in 2014 on a platform that included Medicaid expansion, had been courting the Republican-led state legislature on the issue. But after lawmakers failed to advance his proposal in their latest session, he decided to carry out the policy on his own authority, he said during a press conference at the Alaska Native Tribal Health Consortium headquarters in Anchorage. Absent legislative action to halt or alter the plan, the expansion will take effect Sept. 1, the governor said.

Broadening eligibility for the federal-state health care program could give coverage to as many as 42,000 Alaskans, according to the governor's office. Walker informed the state legislature's joint budget committee of his intent to accept federal funding for the expansion in a letter Thursday. He said he will meet with U.S. Health and Human Services Secretary Sylvia Mathews Burwell to discuss Medicaid expansion next week.

"Alaska and Alaskans cannot wait any longer," Walker said. "This is the final option for me. I've tried everything else," he said of his decision to circumvent lawmakers after months of lobbying them to enact his plan via legislation. "I never give up, and I won't give up."

When Congress enacted the Affordable Care Act in 2010, the law called for a nationwide expansion of Medicaid to anyone earning up to 133 percent of the federal poverty level, which is about $15,650 for a single person and $32,250 for a family of four. But in 2012, the Supreme Court ruled that states could opt out of the expansion. Under Walker's plan, Alaska would join 30 other states and the District of Columbia in voluntarily adopting the policy.

Medicaid expansion has been a major contributor to a historic drop in the uninsured rate since 2014. The 19 states that still reject the expansion are mainly in the South.

Besides Alaska, two other states have joined the Medicaid expansion this year. Montana's version of the policy, favored by Democratic Gov. Steve Bullock and enacted by a majority Republican legislature, awaits federal approval. The plan faces obstacles because the state seeks to add requirements for new enrollees, such as the paying of monthly premiums, that aren't part of traditional Medicaid programs. Indiana officials, led by Republican Gov. Mike Pence, won a federal OK to use the Affordable Care Act's Medicaid financing to expand a state program that uses private health insurance plans and health savings accounts to cover low-income people.

The Obama administration had previously approved modified Medicaid expansions in several other states, including Arkansas, Iowa, Michigan and Ohio.

Fresh off his victory against another Supreme Court challenge to the Affordable Care Act last month, President Barack Obama has vowed to promote Medicaid expansion in the holdout states. He made his case in person during a visit to Nashville, Tennessee, in June. Tennessee Gov. Bill Haslam (R) presented a plan for a version of Medicaid expansion to the state's GOP-majority legislature this year, but lawmakers rejected it. Utah Gov. Gary Herbert (R) also is trying to move a Medicaid plan through his state's Republican-led legislature, but the plan has suffered setbacks.

Walker's plan in Alaska could similarly face resistance from GOP state lawmakers, even with the legislature currently out of session. The Legislative Budget and Audit Committee, which Walker notified of his plans on Thursday, operates even when the legislature isn't in session. The committee will have 45 days to endorse the plan, recommend against it or take no action, according to a press release from the governor's office. Walker said during the press conference that he had advised state Rep. Mike Hawker (R), the committee chairman, of his plans to unilaterally expand Medicaid earlier in the week.

While the governor didn't call for lawmakers to reconvene, he noted that they could choose to do so in order to debate, and possibly attempt to block, his plan within the 45-day window.

Earlier this year, Republicans in the legislature attempted to prevent Walker from acting on Medicaid without new legislation by including language in the state's budget prohibiting any such move. Official opinions from the Alaska Department of Law and from the legislature's legal counsel, however, declared that the effort to block Walker likely doesn't adhere to the state's constitution.

Walker defended his decision on Thursday, saying that previous Alaska governors have used the same authority to accept money from sources outside the state's general fund on seven prior occasions. Governors in other states, including Kentucky and Ohio, also adopted the Medicaid expansion without new legislation.

This story has been updated with additional information from Walker's press conference.

5 Ways Obamacare Can (And Should) Be Fixed

Jeffrey Young   |   June 30, 2015    6:05 PM ET

WASHINGTON -- Obamacare is here to stay. That’s the message from President Barack Obama and other supporters of the Affordable Care Act after their victory at the Supreme Court last week. But dodging a lethal legal bullet is not the same thing as ensuring long-term success. And if health care reform is going to achieve the latter, it’s going to need reforms of its own.

“We’ve got more work to do,” Obama acknowledged after the high court ruled in his favor on Thursday.

The Affordable Care Act has notched some notable successes, like reducing the ranks of the uninsured by millions of people, and Obama must build on that progress to sustain it. Through the rest of his presidency, Obama will face a host of problems with the health care system -- problems his reforms didn’t fix. Whether or not the president can find common ground with Republicans, the public is going to keep looking to him for solutions.

Here are five key ways Obamacare could be strengthened:

Cover More Of The Uninsured

Subsidizing health insurance and expanding eligibility for Medicaid coverage through the Affordable Care Act led to the biggest drop in the uninsured rate since the creation of Medicaid and Medicare themselves. Even though more than 10 million people bought private coverage via a health insurance exchange and millions more have gained Medicaid benefits, enrollment data from this year show that the pace was slower than during the first sign-up period. That makes sense, because the uninsured people who were most eager for coverage, as well as the people who could get the lowest-cost insurance, enrolled as soon as they could.

Just 36 percent of the people who could be enrolled in an exchange plan actually are, according to a Henry J. Kaiser Family Foundation analysis of data from the Centers for Medicare and Medicaid Services. The hard part will be tracking down and signing up the people who remain uninsured, especially among groups with high rates of uninsured, like Hispanics.

A huge part of continuing the success in covering the uninsured will be making in-person help available to people trying to sign up, said Ron Pollack, executive director of Families USA, a nonprofit organization. “The most important thing to do is to have adequate numbers of navigators and assisters,” he said. Families USA released a report outlining its health care reform priorities in January, and Pollack published an op-ed on the subject in the journal Health Affairs on Monday.

Make Health Care More Affordable

It’s right there in the name of the law, and for the people receiving generous health insurance subsidies or no-cost Medicaid coverage, it’s a promise fulfilled. That’s not true for everyone, though. People who earn between three and four times the federal poverty level -- in other words, about $35,000 to $47,000 a year for a single person -- only get small tax credits to cut their insurance costs. People who make more than that get nothing. And health insurance is expensive when you're paying full price.

Add that to deductibles that can exceed $6,000 for an individual and $13,000 for a family purchasing the cheapest policies on the exchanges, and it’s clear there’s an affordability gap.

Health insurance companies opted for high deductibles in many of their plans to keep monthly premiums lower, but Pollack believes they could be more creative. For example, every insurer could offer at least one policy at each “metal” level -- i.e., Bronze, Silver, Gold and Platinum -- that would feature smaller deductibles, but would charge fees when a customer received medical care. Or more insurers could exempt things like primary care physician visits from the deductible.

Big deductibles, which aren’t exclusive to the Obamacare exchanges, can discourage people with insurance from getting health care and can present a barrier to uninsured people trying to sign up, Pollack said. “We want to deter people not getting insurance because they look at the front-end cost of the premium and the deductible and they say, ‘That’s unaffordable,’” he said.

Expand Medicaid In More States

Obamacare has survived two Supreme Court challenges, but it didn’t come away unscathed. In 2012, the court ruled that states could opt out of the law’s Medicaid expansion, which is the main tool with which the ACA sought to provide coverage to the poorest working-age adults. Twenty-nine states and the District of Columbia have joined the expansion so far, but many states with high uninsured rates, like Florida, Louisiana and Texas, still haven’t, leaving their poorest residents with no help.

Obama will visit Tennessee Wednesday to promote Medicaid expansion, which Gov. Bill Haslam (R) hasn’t been able to get past the GOP-controlled state legislature. The administration has worked with other Republican governors and state legislators, including Indiana Gov. Mike Pence, to get forms of the Medicaid expansion in place. It plans to keep negotiations open while states like Alaska and Utah continue their internal debates.

“I am optimistic about the Medicaid issue,” Health and Human Services Secretary Sylvia Mathews Burwell said last week. Burwell outlined parts of the administration's health care agenda in an op-ed for CNN on Thursday.

Fix The 'Family Glitch'

Because of a quirk in the way the Affordable Care Act is worded, low- and moderate-income families aren't eligible for subsidies on the health insurance exchanges if one family member's employer offers health benefits for only that worker, not including a spouse or children, that the law deems "affordable" -- meaning it costs less than about 9.6 percent of household income. For a single person, this policy is meant to ensure those who can get affordable health coverage at work do so, rather than obtain federal subsidies. But the law ignores that family policies are much costlier, and still applies the same standard of affordability. That means family members might go uninsured because they can’t afford the premiums for the employer's plan nor the unsubsidized cost of a policy from the health insurance exchange. It’s called the “family glitch," and it’s estimated to affect as many as 4 million people.

A fix would be simple, and expensive: Congress could merely amend the Affordable Care Act to say people in this situation can sign up on the exchanges and get tax credits. “How quickly that’ll get fixed, I don’t know, because it does cost more money," said Pollack. "But I think it’s got to be a significant priority."

Tackle Rising Prescription Drug Prices

During the late 2000s and early 2010s, prescription drug prices were rising more slowly than before, mostly because big brand-name drugs, like the cholesterol medicine Lipitor, had become available in generic form. But we're in a new era now, with next-generation pharmaceuticals like the hepatitis C cure Sovaldi hitting the market at costs of up to $1,000 per pill or even higher. For people with health insurance policies that require them to pick up a bigger share of their medical costs out-of-pocket, these new miracle drugs are largely unaffordable.

Health insurance companies and others in the private sector have engaged in hardball negotiating with drugmakers to bring down prices, but to limited effect. In the rest of the developed world, governments intervene when pharmaceutical companies charge such high prices. Obama has proposed allowing Medicare to set the prices it pays for these medicines the way it does for hospital services and other things, but the law currently forbids that and the drug industry is strongly opposed.

“Right now, there’s no control over what those costs should be,” Pollack said. “There probably ultimately will need to be some kind of control in prices. I don’t think our country is ready for that... I don’t think we’re going to see any relief in the short term.”

CORRECTION: A previous version of this article inaccurately described the nature of the Affordable Care Act's "family glitch" affecting the spouses and dependents of low- and moderate-income workers who are offered health benefits by their employers. The article has been updated with an accurate explanation of this issue.

No Time To Exhale: The Legal System Is Far From Finished With Obamacare

Jeffrey Young   |   June 25, 2015    4:18 PM ET

WASHINGTON -- President Barack Obama's health care law survived yet another near-death experience Thursday. But that doesn't mean the Affordable Care Act has achieved immortality.

Obama doesn't see it that way, of course. "The Affordable Care Act is here to stay," he said in the Rose Garden at the White House after the high court ruled in his favor on a case called King v. Burwell, which would have wiped out health insurance subsidies for more than 6 million people in 34 states.

But even though Obamacare has beaten back the latest serious existential threat -- which have included dozens of repeal votes in Congress, a 2012 Supreme Court case and Obama's re-election campaign -- that doesn't mean Obama and his allies can rest easy. Congress is still trying to repeal the law, and whoever wins the Republican nomination for next year's presidential campaign could put them over the top if he or she wins the White House.

Litigating the Affordable Care Act has become a favorite pastime for conservatives, and there's no reason to believe that will end soon, despite numerous defeats, both high- and low-profile.

A handful of other legal challenges are wending their way through the court system. And while none appear to be on a fast track to the Supreme Court, they have the potential to do major damage to the landmark health care reform law. They're all seen as long shots, but so were King v. Burwell and National Federation of Independent Business v. Sebelius -- and both of those went all the way to the highest court in the land.

These lawsuits may not have the potential to repeal all of the health care law or to cripple the health insurance market, which the two Obamacare Supreme Court cases could have done, but they could still set back the effort to remake the health care system and extend health coverage to more people.

"The remaining legal challenges either don't go to the heart of the Affordable Care Act or are quite unlikely to succeed -- with one possible asterisk," said Nicholas Bagley, a professor at the University of Michigan Law School in Ann Arbor.

Of these lawsuits, the most dangerous for the Affordable Care Act is House v. Burwell, the case brought by House Speaker John Boehner (R-Ohio) and the rest of the Republicans in the lower chamber of Congress last year, Bagley said.

House Republicans make two main claims in their lawsuit. The first is that Obama exceeded his legal authority when he delayed enforcement of the Affordable Care Act's employer mandate. The second is that the Obama administration illegally spent money on subsidies without Congress appropriating the funds. The King case hinged on the tax credits low- and moderate-income people can claim to reduce their health insurance premiums. This GOP's lawsuit is about subsidies available to the poorest Obamacare beneficiaries that limit their out-of-pocket costs by shrinking their deductibles, copayments and the like.

Junking those subsidies would make the health insurance significantly less valuable to these consumers because they are only available to people with incomes up to $29,175 for a single person and $59,625 for a family of four.

"If that case moves forward, then I think we've got a whole new political circus again. The cost-sharing reduction payments are, I think, almost as important as the premium tax credits. Fifty-eight percent of enrollees get them. It makes health care affordable to low-income Americans," said Timothy Jost, a professor at Washington & Lee University School of Law in Lexington, Virginia. "It would be devastating."

House v. Burwell is still pending at the lowest level of the federal judiciary in the district court for the District of Columbia. Judge Rosemary Collyer has yet to rule on whether the House Republicans even have legal standing to sue the administration, a hurdle they may not be able to overcome, Jost said. But at a hearing this month, Collyer pressed the administration's lawyer about the substance of the House's claims, suggesting she may be sympathetic to their arguments.

Were the lawsuit to prevail, the first consequence would be poor families losing their cost-sharing subsidies, although health insurance companies might instead take the hit by having to pay a bigger share of their customers' medical bills without being compensated by the federal government. Because Congress could rectify the problem by simply appropriating the money, that would give them leverage to force other changes to Obamacare -- as the GOP hoped a win in King v. Burwell would do, Jost said. Jost offered detailed summaries of these pending cases on the website of the journal Health Affairs on Tuesday.

So far, the other lawsuits against Obamacare don't appear very threatening.

Two cases, Sissel v. U.S. Department of Health and Human Services and Hotze v. Burwell, allege, in part, that the Affordable Care Act should be overturned because its individual mandate language didn't originate in the House, where the Constitution requires tax law to be created. Both cases have lost at the appeals court level, but may be reheard by judges.

When Congress advanced the Affordable Care Act in 2009 and 2010, the Senate employed a common legislative tactic to get around this requirement by taking a House-passed tax bill on an unrelated matter, deleting its entire text and copying the health care bill's language into the empty shell that remained. An appeals court rejected Sissel by saying the mandate's purpose isn't to raise taxes (even though it does in practice), and another appeals court turned away Hotze on the grounds that it's illegal to sue the federal government to avoid paying a tax.

Obama's maneuver to quell the furor over health insurance policy cancellations in 2013 -- the broken "if you like your plan, you can keep your plan" promise -- also is under legal review. Obama asked health insurance companies and state regulators to reinstate those canceled plans, even though they didn't comply with new regulations from the Affordable Care Act.

The American Freedom Law Center and the state of West Virginia each sued over this. The American Freedom Law Center contends reviving these plans and expanding the law's hardship exemption from the individual mandate violate the underlying law. West Virginia says it's unconstitutional to ask states to enforce a federal law. The former case is pending at the federal district court in the District of Columbia, and the latter was rejected by that same court, which ruled the plaintiffs had no standing to sue, and has been appealed.

Even though none of these lawsuits might prevail, they aren't the last word when it comes to Obamacare and the courts, Jost said. "I think most of these cases are dead," he said. "But there could be a whole new round of cases."

Democratic Governors Ready To Help If Court Guts Obamacare

Jeffrey Young   |   June 24, 2015    5:01 PM ET

WASHINGTON -- If the Supreme Court strikes down Obamacare subsidies in two-thirds of the country, President Barack Obama won't be the only leader offering to assist states that want to undo the damage.

Officials in states that created their own health insurance exchanges under the Affordable Care Act -- thereby shielding their residents from the possible consequences of the lawsuit currently pending before the high court -- are standing by to help their counterparts in other states get marketplaces up and running that would allow subsidies in those states to flow again.

"If, for any reason, the court rules for the plaintiffs in this case, I'm going to be communicating with my fellow governors about exploring together what we might do," Kentucky Gov. Steve Beshear (D) told The Huffington Post. "I would be open to exploring any and all possibilities."

The Supreme Court could issue a ruling as soon as Thursday in King v. Burwell, a lawsuit brought by conservative and libertarian activists that alleges the Affordable Care Act doesn't permit subsidies for residents of any state where the federal government, and not the state itself, operates the health insurance exchange. If the challenge prevails, 6.4 million people in 34 states will lose the tax credits that help pay for their health coverage, and an even greater number of people are expected to become uninsured, because such a decision would roil the insurance markets in those states.

Kentucky is one of 16 states, plus the District of Columbia, that established health insurance exchanges under the law, so it wouldn't be affected by a ruling that erases subsidies elsewhere. Kentucky's marketplace, called Kynect, enjoyed a much smoother launch than the markets in most other states, and has experienced far fewer problems than the federal system using HealthCare.gov, which had an infamously rocky rollout in 2013. Kynect has proven popular with residents of the Bluegrass State.

"Ours is a national model," Beshear said. "We know how to do this, and there may be some scenarios where we can work together [with other states]."

Beshear said he hasn't talked with other governors about opportunities for Kentucky to collaborate with them in advance of the ruling. "I don't hear that discussed yet," he said, "because, for the most part, no one wants to discuss scenarios that are opposite of where they hope the court will come out."

The most important factor in each of the states with federally run exchange marketplaces will be whether leaders there have the political will to embark on the costly and risky mission of creating a new exchange. Every one of those states, except Delaware, has a Republican governor, legislature or both, which makes it highly uncertain that the necessary momentum would exist in many places. In states like Louisiana, Texas and Wisconsin, the Republican governors have made it clear that they won't seek a state exchange, and 11 states have already enacted laws making it harder to set up those marketplaces.

But given the turmoil that would result if the high court rules to eliminate subsidies, some other states may decide to act. Ten states using federal exchanges have asked the Supreme Court not to block subsidies for their residents, and seven states using the federal exchanges are doing so in formal "partnerships" with federal authorities.

Obama and his lieutenants have stressed that they wouldn't be able to undo a Supreme Court decision eliminating subsidies in federal exchange states without additional legislation -- and the distance between Democrats and Republicans on how to respond to such a ruling is vast. But Health and Human Services Secretary Sylvia Mathews Burwell has said the administration will do what it can to help states seeking to get new exchanges online.

That's where states like Kentucky could come in. In addition to providing general guidance to leaders in other states looking to set up their own health insurance exchanges, Kentucky could, for example, lease out its enrollment technology or partner with other states on certain functions of the marketplace, like customer service. "Obviously, it would be easier today to know how to do this than it was two, three years ago," Beshear said.

Connecticut already took advantage of the success of its Obamacare portal, Access Health CT, by charging Maryland for its technology last year after the disastrous rollout of Maryland Health Connection in 2013. Connecticut is also reportedly in talks with the state-run exchanges in Rhode Island and Vermont about moneymaking and money-saving partnerships.

"We've been trying to help out other states," Connecticut Lt. Gov. Nancy Wyman (D) told HuffPost. "We can hook up with another state and we can go in together and get a call center together. We can bring up their technology through our technology and we can work together that way. And then they will be recognized as an exchange."

The federal government has signaled its flexibility in advance of the court's ruling. New Mexico, Nevada and Oregon, all of which established exchanges but encountered significant problems, have already ceded the enrollment process to HealthCare.gov while continuing to perform other exchange functions, and Hawaii is poised to join them next year. The Department of Health and Human Services also quickly offered conditional approval this month to Delaware's and Pennsylvania's plans to set up marketplaces for 2016, and it did the same for Arkansas' proposal to do so the following year. But other states are essentially just waiting for the Supreme Court decision.

Collaboration between states that already operate exchanges and those hoping to do so could hasten the establishment of new exchanges, and provide opportunities for each state to spend less than they would going it alone. State-run exchanges have already been through two Obamacare enrollment periods, during which they have refined their activities and worked out many of their technical glitches.

"We know from the first go-around that starting this from scratch is very difficult, and at this stage of the game, there is no reason anyone should start from scratch," said Alan Weil, an expert on state health policy and editor-in-chief of the journal Health Affairs.

State leaders who want to create some form of exchange that would restore the subsidies if the Supreme Court takes them away have several ways of going about it, according to a brief published in March by the National Academy for State Health Policy.

The first option would be to set up a full state-run marketplace like those in Connecticut, Kentucky and 12 other jurisdictions. This would be the most expensive and most difficult route for states, because it would require building the entire regulatory and technological infrastructure to manage their new marketplaces.

Alternatively, states could copy Hawaii, New Mexico, Nevada and Oregon by taking on some responsibilities for overseeing this part of the health insurance market but directing residents to the federal system to actually sign up for insurance. A third option would be to pay other states for the use of at least parts of their existing exchanges, akin to Maryland's deal with Connecticut. Some experts argue that states could take a similar tack and pay to use the federal system. Or multiple states could band together into a regional exchange, which is allowed under the Affordable Care Act.

None of these approaches would be easy, even with help from other states that have exchanges in place, Weil said. The technology that checks eligibility for subsidies and manages enrollments could easily be transferred to other states, and states could collaborate to handle features like customer support, but a new exchange would still take a lot of work to set up. For example, said Weil, states would continue to regulate insurance within their own borders and would have to integrate a newly created exchange with their Medicaid programs.

"This is sort of the transplant analogy, which is, you can take someone's heart and put it in, but it's all the connections that matter," Weil said.

And regardless of what states decide if the Supreme Court rules against subsidies in federal exchanges, residents are likely to lose their subsidies this year unless the court takes the unusual step of delaying the effective date of its decision. Governors and legislators in each state will have to debate what action, if any, to take, and only then could they begin the process of actually building any form of health insurance exchange. The odds of all those things happening before the end of the year appear slim.

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Obamacare's First Year Brought Health Insurance To Millions, Official Survey Says

Jeffrey Young   |   June 23, 2015   12:00 AM ET

WASHINGTON -- Millions of people gained health insurance last year as Affordable Care Act benefits took effect, according to the first official accounting by the federal government.

In 2014, 36 million U.S. residents, or 11.5 percent of the population, were uninsured on the day they were surveyed, a decline of 8.8 million people and 2.9 percentage points from the year before, according to the Centers for Disease Control and Prevention's National Health Interview Survey.

The Affordable Care Act remains unpopular, and is besieged politically and legally. The Republican-controlled Congress continues efforts to unwind the law, GOP presidential hopefuls vow to shepherd its repeal and the Supreme Court is poised to rule on a lawsuit conceived by conservative and libertarian activists that would undo much of Obamacare's expansion of health coverage.

But as these new CDC data show, the Affordable Care Act is succeeding in its central aim of helping people obtain health insurance. The findings are consistent with numerous other surveys taken since last year, including recent Gallup polling that shows the uninsured rate continued to decline in 2015, the second year of enrollment through the Obamacare health insurance exchanges.

The national improvement in the share of U.S. residents who have health coverage masks significant variation among the states. In Oklahoma and Texas, 21.5 percent of residents are uninsured -- more than eight times as big a share as in Hawaii, where just 2.5 percent of people have no health insurance. Massachusetts and Delaware have the next-lowest rates to Hawaii's, while Alaska and Florida have the next-highest after Oklahoma and Texas.

uninsured 2014 obamacare
Source: Centers for Disease Control and Prevention

The uninsured rate among working-age adults has returned to the levels seen in the late-1990s and early-2000s. After more than a decade of gradual growth, the share of U.S. residents without health insurance began to fall in 2010, a trend that coincided with the halting recovery from the Great Recession. But the decrease in the percentage of people without health insurance dropped more sharply last year, when the Affordable Care Act's expansion of coverage through Medicaid and private insurance began, the CDC survey found.

uninsured 2014 obamacare
Source: Centers for Disease Control and Prevention

In addition to surveying how many people had no health insurance at the time the CDC interviewed them, the agency found that 51.6 million people, or 16.5 percent of the population, lacked insurance for at least part of the year before the day they were interviewed, and that 26.3 million people, or 8.4 percent, were uninsured for more than a year.

The survey revealed a strong correlation between those states that embraced implementation of the Affordable Care Act and bigger decreases in the uninsured, and between those states that resisted it and smaller effects from the law. In 2012, the Supreme Court made Obamacare's expansion of Medicaid to more poor adults optional for states, and currently 29 states and the District of Columbia have opted in.

The uninsured rate fell 5.1 percentage points to 13.3 percent in states that expanded Medicaid, compared with a decline of 3.1 percentage points to 19.6 percent in states that didn't broaden the program, the CDC found.

The uninsured rate fell more than 5 percentage points in 10 states, all of which expanded Medicaid, except Florida and Georgia. West Virginia's reduction was most dramatic: a 14.8-percentage point decline to 9 percent. By contrast, Louisiana, Maine and Tennessee, which all rejected the Medicaid expansion, show statistically insignificant increases in the uninsured. The uninsured rate in New York, which expanded Medicaid and runs an exchange, was unchanged.

uninsured 2014 obamacare
Source: Centers for Disease Control and Prevention

Americans Aren't Paying Attention To That Huge Obamacare Supreme Court Case

Jeffrey Young   |   June 16, 2015    3:02 AM ET

The Supreme Court is set to issue a ruling in a major Affordable Care Act case that could force millions off their health insurance this June. But if you're like most Americans, you're pretty much clueless about it.

That's right: More than seven in 10 people have heard "nothing at all" or "only a little" about King v. Burwell, a lawsuit brought by conservative and libertarian activists that seeks to eliminate Obamacare's health insurance subsidies for 6.4 million people in 34 states, according to survey results published Tuesday by the Henry J. Kaiser Family Foundation. The share of Americans saying they'd heard nothing -- 44 percent -- about this latest challenge to Obamacare's survival outnumber those who have heard "a lot" or at least "something" by almost two to one.

Although some of those millions who use these tax credit subsidies to purchase insurance are paying closer attention, the survey findings suggest the disappearance of that financial assistance, and the damaging effects that would cause to the health insurance market, will catch Americans by surprise if the Supreme Court sides with the plaintiffs when it issues its decision later this month.

At issue is a brief phrase contained in the Affordable Care Act -- "exchange established by the state" -- that the plaintiffs contend limits subsidies to health insurance exchange marketplaces set up by states like California, Idaho and New York, not the federally operated exchanges in most of the states, including Florida and Texas. The Obama administration maintains the statute provides for subsidies in every state, regardless what governmental entity built the exchanges.

A decision for the plaintiffs would take away subsidies from more than 6 million low- and moderate-income beneficiaries, making their coverage unaffordable and causing most of them to be uninsured. Experts also expect that those with the greatest medical needs -- who are the costliest to insure -- would be more likely to seek to retain their policies. That would drive up expenses for insurers, forcing them to raise rates on their remaining customers, which in turn would cause more healthy people to exit the market.

Awareness of the Obamacare lawsuit is slightly higher than it was three months ago, but remains low. That's despite massive news coverage of the oral arguments about the lawsuit in March, and political jockeying by President Barack Obama and Republicans in Congress as the ruling nears and the the need rises for a solution to the problems that a decision against the subsidies would bring.

obamacare lawsuit poll

Last Monday, Obama said the high court shouldn't have taken up the case in the first place, and the next day gave a speech labeling those who want to see Obamacare's expansion of health insurance coverage to millions of people rolled back as "cynical."

On Capitol Hill, Republicans have rejected Obama's call for a straightforward fix that would restore the subsidies -- and remain divided amongst themselves about whether to do anything at all for those who would lose their subsidies. And the leading GOP proposals so far all would unwind the Affordable Care Act itself, an approach Health and Human Services Secretary Sylvia Mathews Burwell plainly told Congress last Wednesday Obama wouldn't support.

According to the Kaiser Family Foundation poll, the public wants Congress or state governments to essentially undo a Supreme Court ruling that eliminates health insurance subsidies -- which for now puts a majority on Obama's side in a potential dispute with Congress and Republican state officials. The foundation surveyed 1,200 adults from June 2 to June 9.

Sixty-three percent of those surveyed said Congress should simply give the subsidies back. Views on what Congress should do fall on predictable partisan lines: Eight in 10 Democrats and two-thirds of independents favor this action -- but so do almost four in 10 Republicans. And 55 percent of people who live in locales with federal health insurance exchanges want their home states to create their own marketplaces to keep the subsidies flowing.

obamacare lawsuit poll

Most Americans would want subsidies restored even though less than half of the public says it even supports the Affordable Care Act, the survey shows. Just 39 percent of respondents view the law favorably, compared to 42 percent who have an unfavorable opinion of it.

obamacare lawsuit poll

Obama Makes Moral Plea For Health Care Law As Supreme Court Ruling Looms

Jeffrey Young   |   June 9, 2015    2:24 PM ET

WASHINGTON-- President Barack Obama restated the moral case for his health care reform law during a speech Tuesday, asserting, "Health care is not a privilege. It is a right."

Obama's remarks come just weeks or even days ahead of a Supreme Court ruling that could do major damage to the Affordable Care Act -- and reopen the legislative debate about the law more than five years after he signed it. Obama addressed the Catholic Health Association of the United States, a trade group of hospitals affiliated with the Roman Catholic Church, at a conference in Washington.

"The rugged individualism that defines America has always been bound by a shared set of values, an enduring sense that we're in this together," Obama said. "America is not a place where we simply turn away from the sick, or turn our backs on the tired, the poor, the huddled masses. It is a place sustained by the idea, I am my brother's keeper, I am my sister's keeper -- that we have an obligation to put ourselves in our neighbor's shoes and see each other's common humanity."

The flaws in the American health care system, starting with tens of millions of people who had no health insurance, poor access to medical care and unlimited exposure to financial ruin from illness, were problems that needed to be solved, Obama said. "So after nearly a century of talk, after decades of trying, after a year of sustained debate, we finally made health care reform a reality here in America," he said.

Obama cited the Affordable Care Act's successful reduction in the share of Americans without health coverage, and asserted that the changes brought by his reforms couldn't easily be undone.

"Five years in, what we are talking about is no longer just a law. It's no longer just a theory. It isn't events about the Affordable Care Act or Obamacare. This isn't about myths or rumors that folks try to sustain," he said. "This is a reality that people on the ground, day to day, are experiencing. Their lives are better. This is now part of the fabric of how we care for one another. This is health care in America."

Obama mocked the continuing efforts to repeal or otherwise disrupt the law, and reiterated his pledge to fight them.

"We're not going to go backwards," he said. "It seems so cynical to want to take coverage away from millions of people, to take care away from the people who need it the most, to punish millions with higher costs of care, and unravel what's now been woven into the fabric of America."

This is now part of how we care for one another. President Barack Obama

More than 10 million people enrolled into private health insurance plans via the Affordable Care Act's health insurance exchange, and 87 percent of them received tax credit subsidies to help pay for the plans as of March 31, according to data published by the Department of Health and Human Services this month. The law's expansion of Medicaid to more low-income people -- despite being rejected in nearly half the states -- has extended coverage to millions more. The administration estimates 16 million fewer people are uninsured because of the law.

"There are outcomes that we can calculate and enumerate -- the number of newly insured families, the number of lives saved -- those numbers add up to success in this reform effort," Obama said. The White House launched a new website to promote the law Tuesday.

Obama touted the positive effects of his health care overhaul as he awaits a decision from the Supreme Court that could undermine the law and reverse its gains in expanding health coverage to the uninsured.

This month, the Supreme Court is expected to issue a ruling in King v. Burwell, a lawsuit engineered by conservative and libertarian activists that seeks to eradicate Obamacare's health insurance subsidies for millions of people. According to the plaintiffs in the case, a strict reading of the law means these tax credit subsidies are only legal for residents of states that created health insurance exchanges under the Affordable Care Act. The Obama administration argues the law clearly allows subsidies in every state, regardless of whether the state or the federal government operates the exchange marketplace.

The consequences of ruling against Obama would be severe, and would create pressure on Obama, Congress and the states to respond.

The federal government runs the exchanges in 34 states, where 6.4 million people who currently receive subsidies would lose them if the plaintiffs prevail. Since these individuals have low or moderate incomes, most are expected to lose their health coverage. The abrupt exit of millions of customers from the health insurance rolls is further expected to roil the markets in those states, because those with expensive medical conditions are considered most likely to retain their policies, driving up expenses for insurers and leading to rate hikes. Eight million or more people would wind up uninsured, according to estimates from the Rand Corp. and the Urban Institute.

The White House maintains it could do little to mitigate these effects, beyond assisting states that want to create their own health insurance exchanges to preserve subsidies for their residents. To date, only Delaware and Pennsylvania have initiated efforts to establish an exchange if the high court strikes down the subsidies. And Republican governors in places including Louisiana and Wisconsin have declared they wouldn't take action to restore financial assistance for Obamacare enrollees in their states. Mostly, state leaders are waiting to see how the Supreme Court rules while considering their options.

Republicans in Congress are deeply split about how, or whether, to respond to a high court ruling that eliminated subsidies in 34 states -- mainly in those currently governed by the GOP.

Republican members of Congress have floated various proposals to temporarily extend Obamacare subsidies, but these plans are predicated on eventually undoing all of the Affordable Care Act, which ultimately would result in even more people losing health coverage. Senior GOP lawmakers like Senate Majority Leader Mitch McConnell (Ky.) and House Ways and Means Committee Chairman Paul Ryan (Wis.) said Republicans won't unveil their official plans for responding to King v. Burwell until after the Supreme Court rules. But other Republicans in Congress prefer to let the subsidies lapse and do nothing.

Jeffrey Young   |   June 1, 2015   10:21 AM ET

The Supreme Court is expected to issue a hotly anticipated decision soon in a lawsuit that could do major damage to the Affordable Care Act, aka Obamacare.

What's it all about, and who would be affected? Huffington Post health care reporter Jeffrey Young explains in this video.

Read more on the latest Obamacare Supreme Court case below:

The Clock Is Ticking And Republicans Still Have No Serious Obamacare Alternative

The Lawsuit That Could Take Down Obamacare Has A Paper-Trail Problem

A Case Study On Why The Obamacare Lawsuit Is Based On Mythical History

UPDATE: June 4 -- The health insurance enrollment figures cited in this video were derived from a report that counted enrollment as of Feb. 22, which the Department of Health and Human Services published on March 10. The department released new data on June 2, detailing enrollment as of March 31. According to the new report, 7.3 million people were covered by plans purchased via the federally operated health insurance exchanges in the 34 states subject to the Supreme Court ruling, and 6.4 million of them received subsidies. The new report includes additional information about each state, but does not update the calculation of average unsubsidized premiums.

Jeffrey Young   |   May 28, 2015    7:33 AM ET

The Supreme Court is expected to issue a decision in a major new lawsuit against Obamacare this June, and the health coverage for millions hangs in the balance.

This challenge to the Affordable Care Act, called King v. Burwell, came from longtime Obamacare opponents who claim that, because of a key phrase in the law, the federal government may provide tax credit subsidies only in states that operate their own health insurance exchanges. Thirty-four states declined to establish these marketplaces, and instead left that responsibility in the hands of the federal government.

If the Supreme Court rules for the plaintiffs in this case, it would eliminate health insurance subsidies for 7.5 million low- and moderate-income people in those states, causing most of them to become uninsured when their premiums become unaffordable without financial assistance.

Here's how the numbers break down in each state with a federally operated health insurance exchange.

Infographic by Alissa Scheller for The Huffington Post. Jonathan Cohn and Jesse Rifkin contributed reporting.

UPDATE: June 4 -- The numbers displayed on this map are derived from a report that counted health insurance exchange enrollment as of Feb. 22, which the Department of Health and Human Services published on March 10. The department released new data on June 2, detailing enrollment as of March 31. According to the new report, 7.3 million people were covered by plans purchased via the federally operated health insurance exchanges in the 34 states subject to the Supreme Court ruling, and 6.4 million of them received subsidies. The new report includes additional information about each state, but does not update the calculation of average unsubsidized premiums.

This Is What The Latest Obamacare Supreme Court Case Is All About

Jeffrey Young   |   May 26, 2015    7:31 AM ET

President Barack Obama’s big health care reform law is back at the Supreme Court. Justices are expected to issue a decision in June on a new challenge to the law. Depending on which way they rule, either nothing will change or people across the country will start losing their health insurance and the already heated politics of Obamacare will get even more fiery.

Obamacare is at the Supreme Court? Is this a rerun?

Nope. Although the Supreme Court upheld the constitutionality of the Affordable Care Act’s individual mandate in 2012 (and weakened the law’s birth control coverage provisions last year), that wasn’t the end of Obamacare’s legal troubles. Justices heard arguments in March about another lawsuit, King v. Burwell, and this one isn’t about whether Obamacare is constitutional but whether the federal government correctly implemented the law. King v. Burwell is at least as big a deal as the 2012 case, because health insurance coverage for millions of people is at stake.

What is this new lawsuit about anyway?

The plaintiffs, a group of regular people recruited by conservative and libertarian think tanks opposed to the Affordable Care Act, claim that there’s a brief phrase in the law that makes health insurance tax credit subsidies illegal unless they go through a health insurance exchange -- that is, an online marketplace for health plans -- that was set up by a state government. That leaves out the 34 states where the federal government runs the exchange instead.

King v. Burwell is one of several basically identical lawsuits arguing that the IRS broke the law when it published a regulation allowing subsidies to go to people in states with federally created exchanges. Not surprisingly, Republican officials eventually embraced this lawsuit as a cool, new way to ruin Obamacare.

And how has the Obama administration responded to this?

“That’s nonsense!” would be a good way to summarize the legal response to this lawsuit, but of course it’s more complicated than that. What the government argues is that isolating the phrase “an exchange established by the state” from the rest of the lengthy statute is absurd because many other parts of the law assume subsidies are available nationwide, no matter who runs the exchange. Defenders of Obamacare have also emphasized that this is what Obama and the Democrats who wrote the law in Congress always said the Affordable Care Act would do.

How is the Supreme Court expected to rule?

Even though the high court is split between five Republican appointees and four Democratic ones, they won't necessarily decide the case along partisan lines. Of course, during oral arguments, conservatives like Justice Antonin Scalia and Justice Samuel Alito seemed more inclined to accept the plaintiffs' contention that the plain language of the law can't be ignored. Meanwhile, liberals such as Justice Ruth Bader Ginsburg and Justice Elena Kagan made comments suggesting they agree with the Obama administration that the greater context of the law makes it clear subsidies were intended nationally, and that the IRS has the authority to interpret the language that way. And Justice Anthony Kennedy, a Republican appointee seen as a swing vote, expressed concern that reading the law in the manner favored by the plaintiffs would create a "constitutional problem," since it would leave states a choice between establishing exchanges or seeing their insurance markets seriously damaged. Chief Justice John Roberts, who was the deciding vote in the 2012 case, barely spoke that day.

What happens if Obama wins the case?

Things stay the way they are now: Obamacare enrollees can keep their subsidies, and the politicians can continue yelling at each other about whether that’s good or bad.

And what if the plaintiffs win?

The first thing that would happen is those subsidies would disappear for about 6.4 million people in the 34 states that have federal health insurance exchanges. Those tax credits only go to people with low or moderate incomes -- up to about $47,000 for a single person or $97,000 for a family of four. Without that assistance, most of these enrollees wouldn’t be able to afford their insurance anymore and would probably drop it, especially those with the lowest incomes receiving the biggest subsidies.

The subsidies would cease within weeks of a Supreme Court ruling for the plaintiffs, unless the justices decided to “stay” their ruling -- that is, build in a delay in order to give politicians time to maybe do something to protect those people. Absent such protections, the Rand Corp. estimates that 8 million people who have health coverage today would wind up uninsured.

Does any of this affect me in any way?

If you don’t get your health insurance from a federal exchange created by the Affordable Care Act, then it doesn’t, no matter what the Supreme Court decides. That means anybody whose health plan comes from a job or a government program like Medicare or Medicaid. It also means anybody whose insurance came from an Obamacare exchange their home state set up, which includes people in California, Idaho, Kentucky and 13 other states, as well as in the District of Columbia.

If you used an Obamacare exchange in those other states, though, a ruling against Obama is going to hit you in the wallet big-time. That's probably true even if you don’t get subsidies, or if you skipped the exchange and bought your plan directly from an insurance company or through a broker. Experts predict that when millions of people drop their coverage, the sickest ones will be most willing to pay the unsubsidized prices, because they need it more. That, in turn, will drive up expenses for insurance companies, and they’ll respond by raising rates.

So the Supreme Court could repeal Obamacare with this ruling?

No. The rest of the Affordable Care Act would stay in place, such as the guarantee of coverage for people with preexisting conditions and the minimum benefits package for health insurance policies. That's actually the big reason why such a ruling would affect people who buy their insurance from an exchange or directly from a health insurance company: because people with illnesses could still get coverage, but fewer healthy customers would be in the market to pay premiums to cover insurers' expenses. On the other hand, the ruling would significantly curtail two of the law's most controversial provisions. Most of those who would lose subsidies would find the sticker price unaffordable -- defined by the law as more than 8 percent of income -- and become exempt from the individual mandate. And the rule requiring larger employers to cover workers or pay penalties would be nullified in those states, because the penalties are only triggered when employees receive subsidies on the exchanges -- subsidies that would cease to exist.

Are Obama and the Republicans in Congress really going to let all this happen?

It’s hard to predict how the politics would play out, but it would be ugly no matter what. The Obama administration says it can’t do anything about people losing their subsidies unless a new law is passed giving the administration the power to do so. Meanwhile, the Republicans who control Congress can't reach a consensus about what to do. Some of them want to do nothing and just allow the subsidies to go away and premiums to go up, while others want to offer temporary relief as they go about dismantling the rest of Obamacare. Since Obama doesn’t want Obamacare dismantled and he doesn’t want people to lose their subsidies, he probably wouldn’t go for either of those options.

What about my state? Can the governor do anything?

States have always had the option of creating a health insurance exchange for their residents under the Affordable Care Act. Most of them didn’t, in part because of intense opposition to Obamacare in a lot of places and in part because it takes a lot of work and a lot of money. And while states could try to protect their citizens by rushing to get new exchanges in place after the Supreme Court ruling, there isn’t a lot of time and money to go around. Plus, every one of the states subject to the high court’s decision has a Republican governor and/or legislature, except Delaware.

Is it really that hopeless for people who’d lose their subsidies?

Not necessarily. If enough political pressure builds on Congress, Republicans might go along with at least a temporary restoration of the subsidies with few or no strings attached, if they were willing to take heat from conservatives about “endorsing” Obamacare. And despite its assertions, the Obama administration might be able to fast-track the approval of new exchanges in states where the politics compel Republicans to do so (although none of the ways the administration could theoretically do this have ever been tried, and their legality isn't even totally clear).

UPDATE: 6/3, 10:51 a.m. -- This story has been updated with new data on how many people stand to lose health insurance subsidies and with additional information about how the lawsuit would affect the insurance market.

Read more on the latest Obamacare Supreme Court case below:


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Revealed: Medicare's Most Popular And Costliest Drugs

Jeffrey Young   |   April 30, 2015    6:23 PM ET

Medicare spends more than $100 billion on drugs a year, with medications for high blood pressure and high cholesterol among the most commonly prescribed, according to a trove of data released by the federal government Thursday.

The Centers for Medicare and Medicaid Services published 23 million pieces of data detailing the prescribing habits of more than 1 million medical providers in 2013. The information includes $103 billion in drugs, prescribed to 36 million people. It's the latest initiative by the agency to make public previously unavailable information about the massive federal health care program for senior citizens and people with disabilities. The information could prove useful in efforts to reduce program spending and uncover improper or fraudulent prescribing by physicians and others.

The new data highlight a fact understood by practically any American who has ever picked up a prescription at the pharmacy: brand-name drugs are much costlier than generic medications. The drug with the highest number of Medicare billings, lisinopril, cost the program $8.33 per claim, while the medicine that was Medicare's highest expense, Nexium, cost 37 times as much at $308.37 per claim.

The disclosures are part of a larger drive by Medicare to open up its records to researchers, journalists and the public at large. The Centers for Medicare and Medicaid Services previously released data on how much hospitals charge for their services and on the financial ties between physicians and the manufacturers of prescription drugs and medical devices.

"We know that there are many, many smart minds in this country that can help us see these data in new and better ways. We're excited to unleash those minds and see what they can find," Sean Cavanaugh, director of the health care agency's Center for Medicare, said during a conference call with reporters Thursday.

The 10 prescription medicines Medicare paid for most often -- all generic -- generated 306.6 million claims at a cost of $4.14 billion dollars in 2013, or $13.50 per billing to Medicare. Ten brand-name drugs made up the list of the most expensive medicines, and the 4.6 million claims for these drugs cost $18.78 billion, or $343.96 per prescription filled. Those 10 branded pharmaceuticals accounted for almost 5.5 percent of the total spending by Medicare Part D, the program's prescription drug benefit, in 2013.

Nexium, a heartburn treatment known as the "purple pill" that's manufactured by AztraZeneca, cost Medicare the most, totaling $2.53 billion in 2013. Nexium became available as an over-the-counter medicine last year. The Food and Drug Administration approved the predecessor to Nexium, Prilosec, for sale without a prescription in 2010. Nevertheless, Medicare paid 32.3 million claims for omeprazole, the generic version of Prilosec, at a cost of $643 million in 2013.

In addition to Nexium, Medicare spent more than $2 billion on three other prescription drugs in 2013: GlaxoSmithKline's Advair Diskus for respiratory illnesses; AstraZeneca's Crestor for high cholesterol; and Bristol-Myers Squibb's Abilify for depression, schizophrenia and bipolar disorder.

Crestor remains a top expense for Medicare, despite the availability of similar cholesterol medications in the "statin" family as lower-cost generics, including simvastatin (sold by Merck under the brand name Zocor) and atorvastatin (sold under Pfizer's brand name of Lipitor). Medicare paid 36.7 million claims for simvastatin at a cost of $433.7 million in 2013, making it the second-most prescribed drug in the program. Atorvastatin ranked seventh.

A high blood pressure medication called lisinopril accounted for the largest number of Medicare claims in 2013, 36.9 million, and the program spent $307 million on it. Medicines to treat thyroid disorders, pain, diabetes and heart disease rounded out the list of drugs with the most claims. Pharmaceuticals for respiratory ailments, depression, high cholesterol, diabetes, Alzheimer's disease, anemia and cancer made the list of the costliest drugs.

The new data from Centers for Medicare and Medicaid Services includes the total cost of each claim, including the amounts paid by the federal government and the patient, along with any supplementary insurance coverage a beneficiary had. Claims include new prescriptions and refills. These figures do not include spending for pharmaceuticals administered to patients by physicians in their offices, which are covered by Medicare Part B, another component of the program.

The Medicare agency also highlighted patterns in the ways physicians and other medical personnel prescribe drugs. For example, internists and family doctors issued the most prescriptions, followed by nurse practitioners, neurologists and psychiatrists. However, the cost per claim of the drugs prescribed by the latter three types of provider was higher than that of the medicines prescribed by internists and family physicians.

The new information is not merely for academic purposes. When the Medicare agency released data on how much it paid individual doctors last year -- after being sued for the numbers by the Wall Street Journal and others -- it heightened scrutiny on Florida eye doctor Salomon Melgen, an associate of Sen. Bob Menendez (D-N.J.). The data revealed Melgen to be one of the largest recipients of Medicare dollars, and he now stands charged with defrauding the program of more than $100 million. Menendez and Melgen separately were indicted for an alleged bribery scheme that includes accusations Menendez used his office to intervene when the Medicare agency began investigating the physician.

Conservatives Argue The Obamacare Lawsuit Won't Be So Bad After All. That's Nonsense.

Jeffrey Young   |   April 22, 2015    6:08 PM ET

WASHINGTON -- Get ready for a new line from the crowd that brought a lawsuit before the Supreme Court threatening to devastate Obamacare and snatch health insurance away from millions of people: The lawsuit won’t actually devastate Obamacare and snatch health insurance away from millions of people.

It may seem an odd argument coming from conservatives who created and pursued this legal case for the past three years as a terrific way to ruin Obamacare. But if they win, millions of people are going to lose their health insurance, and Americans who aren’t happy about that are going look for someone to blame -- maybe the people who brought the lawsuit, for example, or the Republican politicians who supported them.

The Supreme Court agreed last fall to hear the King v. Burwell case seeking to invalidate health insurance subsidies in more than two-thirds of the states. Since then, backers of this legal attack on the Affordable Care Act have been attempting to reassure the public that congressional Republicans would have a plan to ease the suffering of those who’d lose their health insurance along with their subsidies. But just over a month before the high court is expected to issue its ruling, the best the GOP has come up with are plans to postpone all those people losing their health insurance.

The lawsuit alleges the wording of the Affordable Care Act doesn’t permit subsidies to be provided to people buying coverage in the 34 states where the federal government operates health insurance exchanges instead of the states themselves. Recent analyses by two think tanks, the Rand Corp. and the Urban Institute, project that a loss for President Barack Obama at the Supreme Court would translate into about 8 million people becoming uninsured.

In the absence of a congressional fix to this crisis, trying to persuade the public there isn't much to worry about might be an understandable fallback strategy if you want the lawsuit to prevail. Enter the Heritage Foundation and the American Enterprise Institute, two conservative think tanks in Washington that do.

A few weeks ago, the Heritage Foundation’s Edmund Haislmaier published an “Issue Brief” entitled "King v. Burwell: A Loss of Subsidy Does Not Mean a Loss of Coverage.” That’s a provocative title, considering 87 percent of the 8.8 million enrollees from federal exchanges receive those tax credit subsidies, meaning they have low or moderate incomes.

Haislmaier recently was seen saying it’s "premature" to conclude the huge drop in the uninsured rate since Obamacare passed is the result of Obamacare passing. In this brief, he correctly points out the Affordable Care Act and previous federal and state laws would enable current Obamacare enrollees to switch to some other form of health insurance if the lawsuit he supports succeeds in making their current plans unaffordable. (The brief also chides low-income people for using their subsidies to buy “king-crab-legs-and-steak” insurance rather than take the cheapest possible “powdered-milk-and-frozen-peas” plans.)

“In sum, should the Supreme Court’s eventual ruling in King v. Burwell result in people losing insurance subsidies, the affected individuals will have options for maintaining their coverage or choosing replacement coverage,” Haislmaier wrote. There’s even a chart.

Is that good news for people at risk of losing their health insurance subsidies? Maybe not. “Of course, some might still not be able to afford the unsubsidized premium even if they switched to a less expensive plan,” Haislmaier adds as a disclaimer. Of course.

That seems like it could be a problem, since 83 percent of Obamacare enrollees on the federal exchanges have annual incomes of 250 percent of the federal poverty level or less, which works out to no more than $23,450 for a single person, according to Avalere Health, a consulting firm. In other words, these aren’t Americans with a lot of extra money. And the average value of the tax credits they stand to lose is $263 a month, a substantial amount for people at this income level.

There’s a lot of variation in the price of health insurance, but a look at national average premiums and cost-sharing requirements illustrates what the “Let them eat Bronze plans” line of thinking ignores.

A 40-year-old at the poverty line, which is $11,770 for a single person, would pay $20 a month for a mid-tier Silver plan with tax credits. That amounts to about 2 percent of her annual income. Take away the subsidies, and her premiums jump almost 14-fold to $276 -- or about 28 percent of her income.

What about dropping down to a lesser Bronze policy with higher out-of-pocket costs like deductibles?

That would cost almost 11 times as much as the subsidized Silver plan, at $213 a month, or about 22 percent of her income. Another person making twice as much money as her would see his premiums for the same Silver policy rise by 80 percent, which would eat up 14 percent of his income. His premiums would rise by 39 percent if he switched to a Bronze plan, which would cost him 11 percent of his yearly earnings.

Even opting for a slimmer policy might not make sense for lower-income people, considering how much more Bronze policyholders have to spend before their coverage kicks in. For example, the average deductible for an individual Bronze plan is $5,181, compared to $2,927 for a Silver plan, according to Health Pocket.

And this doesn’t even factor in the effects of a second type of subsidy only available to people earning up to 250 percent of poverty, which reduces their out-of-pocket health care expenses, and which also would go away in the high court rules for the plaintiffs.

These effects are less dramatic up the income scale, but the examples demonstrate why the Affordable Care Act subsidizes health insurance for low- and middle-income households, and why the projections conclude that, for many millions, a loss of subsidy does mean a loss of coverage.

There's another argument about why the Obamacare lawsuit won’t be as bad as everyone else has said. This one comes from Joel Zinberg, a surgeon and lawyer from the Mount Sinai Hospital in New York who’s a visiting scholar at the American Enterprise Institute. In a March article, Zinberg questioned the mere concept of an insurance “death spiral,” not just whether a Supreme Court ruling gutting Obamacare could cause one.

A death spiral is an industry term for what happens when too many sick people and not enough healthy people are buying insurance in the same market. Prices rise, causing people who need insurance the least to drop out; this is called “adverse selection.” That leaves insurers with a group of customers with higher medical expenses, who are more motivated to keep paying for coverage. But then their expenses cause prices to rise further, weeding out more customers, and so on.

“Are ‘death spirals’ real, or just a way to frighten the public?” Zinberg writes, foreclosing the possibility they are both. “There is little reason to believe a death spiral would follow a plaintiff’s victory in King v. Burwell,” he continues.

In contrast to his counterpart at the Heritage Foundation, Zinberg rests his conclusion largely on the realization that tons of people would find unsubsidized health insurance so expensive, they wouldn’t be able to afford it no matter how sick they were and no matter how badly they needed it. So, good news for the insurance markets, then.

Zinberg cites two economic studies of past situations in states that had laws restricting health insurers’ ability to vary prices by health status and age. In these cases, such as in New York in the early 1990s, health insurance markets experienced “adverse selection” but didn’t totally collapse, those economists concluded.

According to the authors of one of those papers, Zinberg is partially right -- with a huge caveat. In emails to The Huffington Post, Bradley Herring of the Johns Hopkins Bloomberg School of Public Health and Mark Pauly of the Wharton School at the University of Pennsylvania said their research does suggest a death spiral may not result from a court decision against the subsidies.

That caveat? They both still believe such a ruling would destabilize the insurance markets in the affected states. The majority of people the Urban Institute projects would lose coverage are those whose subsidies would disappear, and premiums would indeed rise for those who keep their insurance, Herring wrote.

The Urban Institute’s and Rand’s analyses mainly are based on the expectation that lots of people will drop their health insurance immediately after the subsidies go away, and that the disruption caused by so many people fleeing the insurance markets in those states will cause further damage. The problem could especially be acute because the Affordable Care Act would still require health insurance companies to accept any customer, no matter how many pre-existing conditions she has, and would still limit the extent to which older people can be charged more than younger people.

Pauly noted that he supported the Obama administration in the lawsuit, and wrote: “The end of subsidies would mean that millions of people at all risk levels getting subsidies on exchanges would withdraw from the market. If that isn’t disruption I do not know what is.”

The findings of the other paper on which Zinberg bases his case don’t apply to the current situation because the circumstances and insurance markets are too different from the ones studied in the 1990s, wrote one its coauthors, Thomas Buchmueller, the chairman of business economics at the University of Michigan’s Ross School of Business. He served in Obama's White House as senior health economist on the Council of Economic Advisors in 2011 and 2012.

Buchmueller’s conclusion was more blunt. “Eliminating the premium tax credits will have a devastating effect on the individual health insurance market,” he wrote. “A large number of these people will not be able to afford coverage without those subsidies and will therefore likely drop out of the market. It is reasonable to expect that those who stay in the market even after the subsidies go away will be higher risk consumers who know they have a strong need for medical care.”

None of this should be a surprise to anyone who knows how the Affordable Care Act works, or what those who brought the legal challenge expect. Just ask the man in charge of the libertarian think tank that midwifed it, Lawson Bader, president of the Competitive Enterprise Institute.

“Think of this as a domino,” Bader told Reason magazine last month. “If we win, what happens immediately is about 5 million people in 34 states no longer receive subsidies," he said. “The insurance market essentially implodes over a couple of years.”

Montana Legislature Votes To Expand Medicaid Under Obamacare

Jeffrey Young   |   April 18, 2015    1:28 PM ET

WASHINGTON -- Montana is on track to join 28 states and the District of Columbia by expanding Medicaid to cover more low-income people.

Democrats in both chambers of the majority-GOP Montana state legislature have joined with enough Republicans to advance the legislation. The state Senate sent the measure to Gov. Steve Bullock (D), a Medicaid expansion supporter, on Saturday following a state House of Representatives vote a week before. Proponents of the legislation say it will expand health coverage to as many as 45,000 Montanans.

Montana is set to become the second state this year to adopt the Medicaid expansion, following Indiana's action in January. Debate continues on the issue in states including Alaska, Florida, Missouri, Tennessee and Utah, but the chances of more states signing on are steadily decreasing amid staunch opposition from Republican legislators, even in states with GOP governors who want to broaden Medicaid eligibility.

Federal officials must sign off on the Montana Medicaid expansion plan, because it includes new requirements for enrollees, such as monthly premiums. The Affordable Care Act calls for Medicaid eligibility to be broadened to anyone who earns up to 133 percent of the federal poverty level. (For a single person, 133 percent of the federal poverty level would be $15,654.) Under the law, the cost of newly eligible Medicaid enrollees is almost entirely paid by the federal government, and states will never pay more than 10 percent. The Supreme Court made the expansion optional for states in a 2012 ruling.

Montana's Medicaid expansion is coming later than it would have if not for a mishap two years ago. In 2013, Montana state Rep. Tom Jacobson (D) accidentally cast the deciding vote against a Medicaid expansion bill he supported, and state House Republicans declined to allow a re-vote on the measure.

This year, Medicaid expansion advocates in the Montana legislature proved more adept. The state Senate passed a bill last month, but a House committee appeared to bottle up the measure. Democratic and Republican supporters of the bill, however, employed parliamentary tactics to force the full House to consider the bill. That ultimately led to the passage of a slightly different version of the legislation, which the state Senate approved Saturday.

Good Riddance To One Of Congress' Dumbest Rituals: The 'Doc Fix'

Jeffrey Young   |   April 14, 2015    9:52 PM ET

WASHINGTON -- It’s been called “dumb,” “bad policy” and “common-sense-defying." And that’s by the people in charge of it. It’s also called the “doc fix,” and it’s finally letting out its death rattle.

At long last, Congress on Tuesday killed off a policy with no defenders that has served as an excuse for crisis-motivated legislating for years.

Over the past decade and change, the term “doc fix” became shorthand for a nearly annual process by which Congress, facing a big, unintended cut to how much Medicare pays physicians, would scramble to find some way to stop it, as doctors issued loud, mostly empty threats to stop treating Medicare patients. This happened 17 times between 2003 and 2014. Seventeen times.

Rather than actually addressing the policy requiring these cuts and coming up with a new way to pay doctors that actually worked as intended, Congress continually dug itself into a deeper hole, making a permanent doc fix costlier. It’s like putting off repairing that leaky faucet in the bathroom and instead putting a sponge under the drip so they don’t have to hear the splashing sound.

This embarrassing legislative ritual could be seen a precursor to the fiscal brinksmanship and dysfunctional governance that has become more the rule than the exception in Washington. But this year, somehow, Republican and Democratic lawmakers came together, led by House Speaker John Boehner (R-Ohio) and House Minority Leader Nancy Pelosi (D-Calif.), with the full-throated support of President Barack Obama, to overwhelmingly pass a $141 billion bill that fixes the doc fix, and it's is headed to the White House.

Amazing as it is that Congress passed bipartisan legislation that makes substantive policy in the current political climate, what’s even more amazing is it took a dozen years to get it done, despite virtually universal hatred of the old doctor-payment policy.

During those years, Congress dithered and lobbyists lobbied until these cuts in physicians’ fees were mere days or even hours away -- and in a few cases, actually took effect, at least briefly -- until the emergency scared lawmakers enough to do something. That usually amounted to a pay freeze or a small raise for physicians, along with cuts for other medical providers. The fix would be temporary, guaranteeing that Congress would have to revisit the issue within a few months or maybe a year or two, creating the same spectacle all over again.

“That is a lot of bad policy all around. The fact that there’s not a Medicare freight train every year is probably better for humanity,” said Tom Scully, who was administrator of the Centers for Medicare and Medicaid Services in 2002, the first time a doctor pay cut kicked in.

Pretty much the only winners in the doc fix economy were the lobbyists paid to influence it and the health care reporters paid to cover it, two camps that profited from this mess and don’t deserve your sympathy.

Lately, there’s been some strange, advance nostalgia for the doc fix. Defenders say it’s been good for the federal budget because it’s kept physician payments lower than they would’ve been under the system the preceded it, and because Congress usually made other spending reductions to pay for blocking the cuts required by the "sustainable growth rate," or SGR, a complex formula to calculate annual pay adjustments for doctors treating Medicare beneficiaries.

But garbage policy that reduces the budget deficit is still garbage policy. If Congress wanted to reduce the deficit, Congress could have passed deficit-reduction bills.

Chip Kahn, CEO of the Federation of American Hospitals, put it more tactfully. “It’s wrongheaded policy-making. If you’re going to cut people and let it go to deficit reduction, then let’s do that. If you’re going to cut people so that something else doesn’t happen, I can’t believe that’s good policy,” he said.

This year, Boehner and Pelosi decided to rip off the Band-Aid, and the Senate went along with it despite some squawking by deficit scolds. The House leaders pieced together a package that’s not really paid for and adds to the deficit, and told their respective caucuses to take it or leave it. And it worked! Some Senate Democrats complained a bit because they didn’t get to put their fingerprints on it, and some Senate Republicans protested about the legislation's effect on the budget. But once Obama enthusiastically endorsed the Boehner-Pelosi deal, they began to quiet down. The House passed the measure 392-37 last month, and the Senate approved it 92-8 Tuesday evening.

The legislation on its way to Obama's desk would give doctors a small fee increase over the next few years, then link how much they get paid to how well they treat their patients.

All this was necessary because of a policy enacted in 1997 that pretty much everybody knew was bad only a few years in. Back in the ‘90s, Congress wanted to curb rising Medicare spending on physician services, and concocted the "sustainable growth rate" policy. Turns out, only the third word in the name was true.

“The doctor policy here was never intended to reduce doctor payment as much as it did,” said Kahn, who helped create the maligned physician-payment system as a House Republican aide back in the 1990s.

This problem first reared its head in 2002, when the SGR cut Medicare payments to doctors by 4.8 percent. Nobody wanted this, but Congress let it happen anyway. That was the last time they did.

“The docs really got angry,” said Scully, now a health care lobbyist and investor. The docs stayed that way.

Virtually everyone agreed that the SGR policy didn’t work, and had to be replaced with some other method of restraining physician payments. But the usual intra- and inter-party squabbling, a ton of lobbying and a rising price tag made a permanent replacement harder and harder to achieve.

“There’s no fun way around it,” Scully said. “There have been a lot of efforts to try to fix it, but they were always painful.”

During the intervening years, the formula kept calling for lower payments and Congress kept stepping in to stop them, usually by taking money from hospitals and other health care providers to pay for it.

“There was a constant sense of crisis,” Kahn said. “From a provider’s standpoint, it was an annual or semi-annual nightmare because it meant that you were spending all your time not worrying about big-picture policy, but worrying about how your rates might be cut in some way so that Congress could get through the next six months or year,” Kahn said.

To make these interventions seem cheaper, Congress started pretending that one year’s cuts would simply be delayed and added to the next year’s cuts. Then they’d block that one, too, and so on. That’s why the reduction that was slated to take effect this spring was more than 20 percent.

So does the end of the doc fix mean the end of legislative brinksmanship and the beginning of a new era of bipartisan cooperation in which lawmakers will actually manage the federal government like they’re supposed to? Hardly. The same week the House passed the Medicare bill, Republican senators were trying to repeal Obamacare again.

But does doing away with the farcical doc fix process at least mean Congress has solved the problem of how Medicare should pay physicians? Once again, hardly. The “sustainable growth rate” system was considered reform in 1997, and look what happened. Obama hasn’t even signed the new bill and critics are already predicting the new policy will fail based on rosy assumptions about its effectiveness … meaning someday, we may need a doc fix fix fix.