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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.

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 7.5 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, and that’s probably true even if you don’t get subsidies. 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.

Are Obama and the Republicans in Congress really going to let that 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).

Got more questions about the Affordable Care Act and the Supreme Court? Join Huffington Post reporters Jonathan Cohn and Jeffrey Young for a chat on the HuffPost Politics Facebook page June 2.

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

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.

Uninsured Rate Gets Lower And Lower, Thanks To Obamacare

Jeffrey Young   |   April 13, 2015    3:05 AM ET

WASHINGTON-- The Affordable Care Act was designed to slash the percentage of Americans who lack health insurance, and it's working.

The uninsured rate fell to 11.9 percent during the first quarter of this year, 1 percentage point below the rate at the close of 2014, according to the findings of a Gallup-Healthways Well-Being Index poll published Monday. The decline coincides with the start of benefits for new Obamacare enrollees at the beginning of 2015.

The latest uninsured figure from the Gallup survey is the lowest since the polling firm began tracking the number in 2008, and contributes to a remarkable decline of 5.2 percentage points in the share of people without health coverage since the end of 2013, just before the first wave of Obamacare health insurance enrollees joined the ranks of the insured.

uninsured rate obamacare
Source: Gallup

African-Americans, Hispanics and people with low incomes saw the greatest gains in insurance coverage, Gallup found.

Some of the increase in the proportion of Americans with health coverage likely is related to the improving job market, and the health benefits provided by employers, Gallup notes. But the pollsters conclude that Obamacare is mostly responsible for the current trend because the uninsured rate is lower than it was in early 2008, when the economy was in recession.

About 12 million people are covered by private health insurance obtained via the exchanges, according to the Department of Health and Human Services. A separate analysis published by the department last month estimates that 16 million fewer Americans are uninsured because of the Obamacare coverage expansion, including the exchanges and Medicaid.

Were more states to expand Medicaid under Obamacare, the uninsured rate would fall more sharply, as it did in Indiana earlier this year. Previous surveys showing state-by-state numbers illustrate that Obamacare's effect on the uninsured is diminished by states' refusal to expand Medicaid.

Although Montana appears poised to adopt the Medicaid expansion this month, efforts in states such as Alaska, Missouri, Tennessee and Utah this year have been stymied by Republican opposition. Almost 5.5 million people had enrolled into Medicaid because they qualified under the expansion in 28 states and the District of Columbia, the Department of Health and Human Services reported Friday.

The sharp reduction in the uninsured rate since Obamacare benefits began to take effect last year could soon be undone, however. The Supreme Court is slated to rule in June ona lawsuit, King v. Burwell, that claims the Affordable Care Act's subsidies can only be provided in 13 states and the District of Columbia, which operate their own health insurance exchange marketplaces, not in the federally run exchanges in the rest of the country.

A high court ruling for the plaintiffs would invalidate the subsidies received by more than 85 percent of exchange enrollees and destabilize the insurance markets in states with federal exchanges. The Rand Corp. estimates this would result in 9.6 million people becoming uninsured.

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

Jeffrey Young   |   April 6, 2015    9:18 AM ET

WASHINGTON -- Four years ago, Alabama’s new Republican governor, along with the state's first majority-GOP legislature since Reconstruction, faced a tough, high-stakes decision: Make the best of a federal health care reform law they hated, or stiff-arm President Barack Obama.

Even in this conservative Southern state, it wasn’t an easy call. Gov. Robert Bentley (R) had campaigned on a platform that supported creating a health insurance exchange, a pillar of the Affordable Care Act, which he otherwise opposed. Five months after taking office, Bentley impaneled a commission to advise him whether Alabama should establish a state-run exchange or let the federal government create one for them. The key state legislators got to work.

The Bentley administration, the Alabama legislature and the governor’s Alabama Health Insurance Exchange Study Commission weighed many of the same issues their counterparts in other states did. How would they finance the exchange's operations? Should a state agency or some other entity manage a new marketplace? How heavily should insurance companies be regulated? Would it better for Alabama to exert at least a little control over Obamacare, or to just let the U.S. Department of Health and Human Services do the work?

One thing they didn’t seem to consider was whether Alabamians would be able to receive subsidies to make their health insurance more affordable if the state defaulted to a federally operated exchange, according to documents and interviews with principal figures in the debate.

The absence of consideration of that critical provision is remarkable in light of judicial and political developments over the past year. In June, the Supreme Court is expected to issue a ruling on King v. Burwell, a lawsuit alleging that these tax credits should only be available in state-run exchanges.

The consequences for those in Alabama and 33 other states who get health insurance from federally operated exchanges could be dire. More than 220,000 Alabamians are enrolled in plans obtained on the federal exchange, and more than 165,000 of them receive subsidies that could be eliminated by the high court, according to federal data compiled by the Henry J. Kaiser Family Foundation.

The plaintiffs in King v. Burwell, and their allies, want the Supreme Court and the American public to believe not only that the precise wording of the Affordable Care Act -- the phrase “established by the State” -- makes these subsidies permissible only in state-run exchanges, but that this was the clear intent of Congress and was fully understood by state officials when they were deciding which path to choose.

“Any English speaker would immediately understand that no subsidies are available for coverage obtained on an exchange established by HHS,” reads the brief filed by the plaintiffs to the Supreme Court.

And here’s what it says in an amicus brief signed by Alabama Attorney General Luther Strange (R) and his counterparts in five other states in support of the lawsuit: “In making their exchange-establishing decisions, the states were well aware that the plain text of Section 36B conditioned the availability of tax credits on states establishing exchanges.”

If that was the case four years ago, no one told Alabama state Sen. Jim McClendon (R), a native English speaker who co-chaired Bentley’s commission while a member of the state House of Representatives, which unanimously passed a bill in April 2012 to establish an Alabama health insurance exchange.

“No. No. No. That was never, never brought up,” McClendon said in an interview with The Huffington Post last month. “I was unaware of that stipulation in the Affordable Care Act, and I would almost have to guess that anybody involved in this process was not aware of it. I was a little surprised when it came up eventually. Nope. I was the chairman of the commission and I was totally unaware of that.”

In other words, according to McClendon, at no point during the commission’s five meetings between September and November 2011, nor during a legislative debate that stretched into the spring of 2012, did anyone conceive of the most significant consequence that could result from Alabama opting for a federally run health insurance marketplace. The commission ended up unanimously recommending a state-run exchange.

alabama state capitol

Three other people who served on the 15-member Alabama Health Insurance Exchange Study Commission, as well as Robert Carey, a Boston-based consultant hired by the state Department of Insurance to advise the panel, also said the tax credits issue never came up during the commission’s work.

“Never. It was never discussed,” said Carey, who also worked with Delaware and Tennessee on their exchanges at the time, when he was a subcontractor working for LMI, a Tysons, Virginia-based government contractor. “It was never a consideration that they weren’t going to get subsidies if they deferred to the feds. I mean, I was there at every commission meeting and I was presenting, ‘Here are your options, here’s what I think it might cost you,’ and we did those type of calculations."

“It is mind-boggling to me how everyone has now kind of glommed on to this. ‘Oh, yeah. This was totally discussed, and we knew subsidies wouldn’t be available if we went to the federal exchange.’ It’s just hogwash,” Carey said.

alabama obamacare supreme court
Jim McClendon (left), then a member of the Alabama House of Representatives and now a state senator, with Gov. Robert Bentley (seated) in 2012.

HuffPost also interviewed Richard Brockman, an attorney at Burr & Forman in Birmingham who represented the Alabama Nursing Home Association on the commission; Rosemary Elebash, state director of the National Federation of Independent Business in Montgomery, who was appointed to the panel by Alabama Senate President pro tempore Del Marsh (R); and Ron Perkins, vice president of Birmingham-based Doozer Software, who was appointed to the commission by Alabama House Speaker Mike Hubbard (R).

Here’s how they responded to the question of whether they discussed the possibility that tax credits wouldn’t be available if Alabama opted for a federal exchange.

Brockman:

No, no, no. I mean, no, no, no. I mean, the notion of finding a needle in the haystack hadn’t occurred to anybody at the time... No, no, no. It never came up, and that is something I would absolutely have remembered.

Elebash:

That was never a discussion. Nobody even knew that... I don’t remember any discussion about that. The only thing that I can remember is, you either establish a state exchange or the feds are going to do it for you. I mean, that was essentially the discussion.

Perkins:

I don’t remember that coming up. I really don’t. I really don’t ever remember that ever being brought up as an issue... I don’t ever remember anybody saying, ‘Well, if we do this and let the feds do it, this is the trade-off down the road'... I’m almost positive somebody would’ve brought it up... During the time, we didn’t know that. After the commission, that’s when all that stuff started coming out. We were like, ‘Oh, wait a minute.’ That could’ve really changed, obviously, the advice to the governor, because I don’t think he would’ve even said we’re not going to do it if it was clear at that point in time, all the way back four, five years ago, that if you don’t do this, here’s the side effect. Because that’s a huge trade-off.

The remaining commissioners either declined to speak to HuffPost, didn’t respond to phone calls or emails, or couldn’t be reached. These parties include Alabama Insurance Commissioner Jim Ridling and state Sen. Greg Reed (R), the co-chairman of the commission and then-chairman of the Alabama Senate Health Committee.

alabama obamacare supreme court
Rosemary Elebash (right) with Alabama Gov. Robert Bentley and first lady Dianne Bentley in 2012.

In addition, HuffPost reviewed hundreds of pages of documents that LMI and Mathematica Policy Research presented to the commission and prepared for a separate series of stakeholder meetings organized by the Alabama Department of Insurance in May and June 2011. None of these documents advised of the possibility that subsidies would be contingent on the type of exchange. Local news stories about the exchange process in 2011 and 2012 that HuffPost reviewed also don’t mention the issue.

This evidence, or lack thereof, reveals a major problem with the claims underlying the Obamacare lawsuit, and is consistent with the assertions of Democratic members of Congress and their aides, along with those of Obama administration officials. These findings also mirror those from a previous HuffPost investigation of documents from numerous other states.

HuffPost did speak to two individuals from Alabama who made contrary, but dubious, claims that the legislature and the commission did, in fact, consider the subsidies question during the time before Bentley rejected a state-run exchange in December 2012.

One was then-Rep. Greg Wren, the lead Republican advocate for an Alabama exchange in the state House, who resigned after pleading guilty to corruption charges last year and currently operates a lobbying and public relations firm in Montgomery. The other was Thomas Younger, now a senior vice president at J. Smith Lanier & Co. in Huntsville, whom Marsh, the state Senate leader, appointed to the commission to represent Alabama’s insurance agents.

Wren and Younger insisted that the subsidies issue now at the heart of the Supreme Court case was part of their calculations at the time, and that it was widely discussed by policymakers including commissioners and lawmakers.

“I’ve got it in my notes,” said Younger, who also said Carey advised the commission about the matter, contrary to Carey’s own account. “Very clearly, it was brought up and discussed."

Younger also stated, incorrectly, that these subsidies would only be available for the first two years that any health insurance exchange existed. The Affordable Care Act does not include an ending date for these subsidies. Younger didn't respond to follow-up requests to provide his documentation, nor did he provide an explanation for why his account conflicts with those of McClendon and others.

Wren was the author of the health insurance exchange bill the state House passed in April 2012, and he championed a state-run marketplace until Bentley’s final decision in December of that year to forgo a state exchange. Wren told HuffPost he still believes Alabama should have its own exchange.

Wren claimed in an interview that he was aware, early on, of a provision in the law that would restrict subsidies to those who purchased coverage on state exchanges. But in a subsequent email, his account shifted. Wren first said that issue came to his attention in 2009, before Obamacare had even passed. In a subsequent email, he wrote that he had misspoken during the interview, and said he'd actually learned of this phrase in 2011.

“I believed at the time that for many reasons, including the possible favorable premium treatment to individuals purchasing from a state exchange, that Alabama should consider this over a federal,” he wrote.

alabama obamacare supreme court
Greg Wren, then a member of the Alabama House of Representatives, in 2011.

There is little evidence to back Wren's claim that he was aware of the now-controversial provision in Obamacare during his state’s debate over whether to establish an exchange. The former legislator could not offer an explanation for why his version of events differs from those of McClendon and the others interviewed for this article, or why it isn’t reflected in official documents or media accounts from the time.

“At this point I can only say is [sic] I remembered back as best I could,” he wrote in an email.

Wren also acknowledged that he has no documentation from 2010 through 2012 to support his assertions that he understood the phrase “established by the state” could mean that subsidies wouldn’t be available in federal exchanges. The Alabama legislature does not transcribe floor or committee proceedings, so no official record exists of the debate on Wren’s bill.

Wren was often quoted in the local and national press speaking about the advantages of state-run health insurance exchanges in 2011 and 2012, but HuffPost couldn’t find any articles that cited him saying the subsidies wouldn’t be available in federal exchanges.

What defined Alabama's debate over the exchange wasn’t the availability of subsidies. At first, policymakers focused on matters such as how to finance the exchange. Over time, the shifting politics of Obamacare drove action -- and inaction -- in Alabama as Republicans nationwide coalesced around a strategy of complete opposition and obstruction of the law.

Led by Wren -- and initially by Bentley -- Alabama gave sincere consideration to the idea of setting up a health insurance exchange. Prior to becoming governor, Bentley declared that he supported health insurance exchanges, and it was part of his agenda when he took office in 2011. In the meantime, Wren, McClendon and other lawmakers in favor of an Alabama-run exchange were working on the issue in the legislature, but didn't progress so far as a committee vote that year.

The likelihood of a state-run exchange dwindled throughout 2012. The U.S. Supreme Court was set to rule on a previous lawsuit challenging the constitutionality of the Affordable Care Act’s individual mandate and expansion of the Medicaid program. And former Massachusetts Gov. Mitt Romney (R) was challenging Obama’s re-election bid with a vow to repeal Obamacare. Like many other governors from both parties at the time, Bentley cited uncertainty about the court and about the election as reasons to delay making a decision on the exchange.

There were other signs indicating that Bentley’s support for a state exchange was cooling. Three months after his commission recommended a state exchange, the governor dismissed the report, saying ''I'm just not very enthusiastic about it," according to The Birmingham News. In April 2012, Wren complained to the press about campaigns by national anti-Obamacare groups undermining support for his plan. Soon afterward, the Alabama state House approved legislation to establish a state exchange without a single dissenting vote, but the state Senate stalled that legislation in May. The same month, Bentley’s office announced that he would veto the House-passed bill, calling it premature.

Finally, Romney lost, and in December 2012, Bentley announced that Alabama wouldn’t establish an exchange nor expand Medicaid, citing the cost. Bentley also articulated his desire to maintain a united front against Obamacare with his fellow Republican governors, most of whom took the same stance.

The announcement marked Bentley’s first public reference to the legal issue that would ultimately become King v. Burwell. Bentley mentioned the first such lawsuit to make this argument, which Oklahoma Attorney General Scott Pruitt (R) filed in September 2012, but Bentley apparently misunderstood its consequences.

According to a report by Alabama Media Group, Bentley evidently believed the Oklahoma lawsuit would invalidate federal exchanges entirely, not merely the subsidies. "We believe the federally facilitated system they will try to set up, we believe that is unconstitutional," Bentley was quoted as saying.

A Bentley spokeswoman didn’t respond to emailed questions for this story.

CORRECTION: An earlier version of this story misstated that Robert Carey was an employee of LMI, rather than a subcontractor, and that he worked on health insurance exchange planning in West Virginia.

Here's How Obamacare Is Going To Affect Your Taxes

Jeffrey Young   |   April 1, 2015    7:35 AM ET

Taxes are a pain. Health insurance is a pain. This year, Americans will suffer both when they file their income taxes. Ouch.

The Affordable Care Act, aka Obamacare, inserted health insurance into tax season in two ways, affecting nearly all of us. The first is the law's mandate that almost all U.S. residents get health coverage or pay a penalty. The second is the tax-credit subsidy that millions of Americans received via Obamacare's exchanges to lower their health insurance premiums.

Oh, and there are new IRS forms, too.

"The ACA has made health care a tax issue and, in that sense, everyone will see an impact on their tax return this year," said Kathy Pickering, executive director of the Tax Institute at H&R Block. "It may potentially impact their refund."

The tax-filing deadline is just two weeks away, on Wednesday, April 15. Before you freak out, rest assured that little has changed for about 80 percent of Americans. Still, some people will have to jump through new hoops -- and might see big effects on their tax refunds or bills.

It's easy enough to figure out which camp you fall into. Here's what each group of Americans will have to do:

I Get Health Coverage From An Employer Or A Government Program Such As Medicare Or Medicaid

When you file your return, you hardly have to do anything different. There's a new line on the 1040 -- line 61, to be precise -- where you attest that you did, in fact, have health coverage this past year. If that's the case, then mark it down here, and you're done.

"All that they will need to do is, in effect, check a box on the front of the return," Pickering said.

Make sure it's true that everyone in your household was covered in 2014, though, including those who may have had different insurance from you.

For the more than 8 in 10 Americans who had one of these forms of coverage, tax filing is pretty much business as usual this year. So it's horrible, but not more horrible.

I Bought My Health Insurance From An Obamacare Exchange And Got Tax Credits

The good news is, tax credits made your health insurance more affordable. The bad news is, you now have to prove you had insurance this past year, and that you didn't get too much or too little of a subsidy. If your tax credit was too large, you'll have to pay back at least some of it. Almost 12 million people nationwide enrolled through an exchange for this year, and 87 percent of them qualified for tax credits.

If that's you, the first thing you'll need is one of those new forms, the 1095-A. The health insurance exchanges for each state -- whether federal or state-run -- sent these to households that bought private insurance policies from them (as opposed to Medicaid or the Children's Health Insurance Program). This is your proof of insurance.

Those 1095-A forms were supposed to arrive in your mailbox by Feb. 2, but there have been complications. The federal government provided incorrect information to hundreds of thousands of customers who used HealthCare.gov, and some state exchanges, including California's and Minnesota's, also had problems. If you already filed your taxes based on these inaccurate numbers, the IRS won't require you to refile, but taxpayers who think they'd get a bigger refund if they refiled can do so.

If you don't have your 1095-A, you can download the form from the exchange website or call your exchange and ask it to send you one. You may get more than one form, depending on how each member of the family was covered. If you see any inaccuracies on these documents, contact your insurance exchange.

The 1095-A shows how much your total insurance premium was and how large a tax credit you got each month you were covered. You'll need that information to fill out another form, called the 8962. (Yes, a form to fill out a form.)

There's a lot of gobbledygook behind it, but basically the IRS needs to make sure you got the right amount of financial assistance for your health coverage.

When you applied for a credit, you told the exchange what you expected to earn in 2014, and that number was used to calculate your subsidy. Now, when you file the 8962 with your taxes, you're running the numbers again based on what you really made. If those amounts are different, your tax credits will have to be adjusted. People who owe the IRS can set up payment plans.

How many people will see their refunds cut (or face a tax bill), and how many will get money back? The answer, according to the Henry J. Kaiser Family Foundation, is that half of tax credit recipients will owe at least some money to the IRS because their incomes were higher than anticipated, while 45 percent of them will get bigger refunds because their income was lower than they estimated. The average amount owed will be $794, with higher-income earners being required to repay more than low-income households, and the average refund will be $773, the Kaiser Family Foundation estimates.

It makes sense: People's incomes and lives change all the time. Maybe you got a raise. Maybe your hours were cut. Maybe you got married. Obamacare customers are supposed to report changes like that to the exchanges so their subsidies can be adjusted during the year. The maximum amount anyone may owe the IRS varies by income and family size, from $300 to $2,500 for those who earned between the federal poverty level -- which was $11,670 for a single person last year -- and four times that amount. Anyone who received tax credits but whose income exceeded 400 percent of the poverty level could have to pay back all the tax credits they received.

Oh, here's another annoying thing: If you got Obamacare subsidies, you can't file your income taxes with the 1040-EZ. Instead, you have to use the longer 1040.

I Have Health Insurance That Isn't From A Job Or The Government And I Didn't Get Any Tax Credits

About 15 percent of people who bought their policies through an exchange didn't get subsidies, and a few million more bought policies directly from an insurance company, bypassing the exchanges. These folks have to do more than people with job-based insurance or Medicare, but less than their subsidized neighbors.

Basically, if you bought an unsubsidized plan from an Obamacare exchange, take the information from your 1095-A and put it on your 8962, and check off line 61 of your 1040. If you didn't use an exchange and bought your insurance directly from the company, you just need to care about line 61. When it comes to taxes, that counts as easy.

One more thing for unsubsidized people who used an exchange: You might still be able to get tax credits. If you earned less than four times the federal poverty level -- meaning $46,680 for a single person and $95,400 for a family of four -- you can apply for a subsidy via the exchange. If you skipped the exchange, then this isn't possible, no matter what your income was.

I Don't Have Health Coverage At All

Obamacare's individual mandate requires most legal U.S. residents to get covered, so you might be subject to a tax penalty if you were uncovered for more than three months. The formula is complicated, but the penalty starts at $95 and goes all the way up to about $11,000. (Read this for more information.) If you didn't earn enough money to pay taxes, meaning you made less than $10,150 as a single person under 65 or more for other types of households, then there's no health insurance mandate for you, and you don't have to file a return.

There are tons of exemptions to the Obamacare mandate, but you have to apply for most of them. The IRS and the Department of Health and Human Services really want to make sure that people who are exempt avoid the penalty, and they launched a public outreach campaign last month to get the word out. As part of that, federal authorities created a tool on HealthCare.gov designed to help taxpayers figure out whether they can get an exemption from the mandate and the fine, and to explain how to apply.

The majority of exemptions are granted by the IRS, but some have to come from the exchange. You'll need form 8965 to include a mandate exemption on your tax return.

The idea behind the mandate was that everyone who can "afford" insurance should buy it, to avoid saddling the rest of us with the cost of their medical care. The Affordable Care Act says insurance is "affordable" if it costs 8 percent of your income or less. If insurance was available to you below that price and you didn't get coverage, you'll have to pay a penalty.

If you really couldn't find "affordable" coverage, then you're exempt. But you do have to document that to the IRS. Other exemptions you can claim on your tax return include living abroad or being in prison.

For some exemptions, you'll have to apply to your insurance exchange. Those exemptions include belonging to a religion that objects to insurance; living in a state that didn't expand Medicaid under Obamacare and left you ineligible for low-cost or free coverage; or getting your pre-Obamacare insurance policy canceled. And the exchanges will provide "hardship" exemptions for a slew of reasons, like being evicted or filing for bankruptcy.

You can file your taxes and claim those exemptions while waiting for your exchange to tell you whether you're exempt. If it says no, then you can sort that out with the IRS later. And people who owe the penalty for 2014 and don't have health insurance this year are allowed to sign up for a plan in most of the country, because the federal government and almost all state-run exchanges re-opened enrollment to accommodate tax filers in these circumstances. Getting covered now won't make the 2014 fine go away, but it will eliminate or reduce the penalty you would otherwise owe a year from now.

I Need Help!

Yeah... about that. Calling the IRS telephone hotline will probably be a nightmare, in large part because of budget cuts. The health insurance exchange hotlines can provide help with issues like exemptions from the mandate, but not with other tax questions. There are other options for assistance, thankfully, but you'd better hurry -- April 15 is right around the corner.

Companies like H&R Block, as well as accountants in your area, will do your taxes with you, for a price. There are online applications, such as Intuit TurboTax, that also charge money. Some of these companies offer some free assistance as promotion for their paid services.

If you made less than $60,000 a year in 2014, you can use the IRS' Free File option, but you'll still have to do a lot of math yourself. If you made less than $53,000 a year, you can take advantage of tax preparers participating in the IRS' free Volunteer Income Tax Assistance program. The IRS' Tax Counseling for the Elderly program is available at no charge to people 60 and older. And Enroll America will offer no-cost local help using Intuit TurboTax.

An earlier version of this story was published on Jan. 26 with the headline "Here's How Obamacare Is Going To Affect Your Taxes."

16 Million Fewer Uninsured Thanks To Obamacare

Jeffrey Young   |   March 16, 2015   11:22 AM ET

WASHINGTON -- More than 16 million Americans gained health coverage because of the Affordable Care Act, mainly via the law's health insurance exchange and Medicaid expansion, according to an analysis published Monday by the Department of Health and Human Services.

The government estimate is consistent with numerous surveys taken over the past two years. The Health and Human Services report issued Monday is based in part on findings from the polling company Gallup, which found the uninsured rate has fallen from 20.3 percent in October 2013, when Obamacare sign-ups began, to 12.3 percent during the first quarter of this year.

The latest figures stand as more evidence that Obamacare is achieving one of its core goals of reducing the number of uninsured Americans, even as the Affordable Care Act remains embattled in Congress and faces an uncertain future at the Supreme Court.

“Since the passage of the Affordable Care Act almost five years ago, about 16.4 million uninsured people have gained health coverage -- the largest reduction in the uninsured in four decades," Health and Human Services Secretary Sylvia Mathews Burwell said in a written statement accompanying a new report from the department.

These gains in the national uninsured rate could be reversed. The Supreme Court heard oral arguments this month in a lawsuit, King v. Burwell, that alleges the Affordable Care Act's tax credit subsidies are only available in 13 states and the District of Columbia, which operate their own health insurance exchange marketplaces. The federal government set up the exchanges in 34 states, and millions of residents would lose their subsidies if the high court rules for the plaintiffs. The Rand Corp. estimates this would result in 9.6 million people becoming uninsured as their health insurance becomes too expensive and the markets in those states destabilize.

According to the Health and Human Services report, 14.1 million people gained health coverage by securing private insurance or signing up for Medicaid through an exchange. An additional 2.3 million young adults got coverage under an Affordable Care Act provision allowing those under 26 years old to remain on their parents' insurance policies.

The second open enrollment period for the health insurance exchanges officially closed in February, and federal officials reported last week that sign-ups for private coverage had reached nearly 12 million people. Enrollment reopened Sunday in states with federally run exchanges for people who learn when they file their taxes that they owe a penalty for not having coverage last year. Most other states are also allowing people in these circumstances to access their exchanges.

In addition to the millions who obtained private health insurance, almost 11 million more people are receiving coverage from Medicaid or the Children's Health Insurance Program compared to October 2013, when the first Obamacare sign-up period began. Twenty-eight states and the District of Columbia adopted the Affordable Care Act's more generous eligibility standards for Medicaid, while the remainder have refused to do so.

The federal government will spend $1.2 trillion over the coming decade expanding health coverage, the Congressional Budget Office projected this month. That's down 11 percent from a budget estimate issued in January, and even lower than earlier CBO predictions.

obamacare costs

Source: Congressional Budget Office and Joint Committee on Taxation

Obamacare Enrollments Hit Nearly 12 Million, Top Health Official Says

Jeffrey Young   |   March 9, 2015    3:39 PM ET

WASHINGTON -- Close to 12 million people are covered by health insurance plans purchased from an Obamacare exchange, Health and Human Services Secretary Sylvia Mathews Burwell said at the White House Monday.

More than half of these enrollees are new to the program, said Burwell, speaking at an event commemorating the close of the second open enrollment period for subsidized private health insurance plans under the Affordable Care Act's exchange marketplaces. The enrollment total surpasses the Department of Health and Human Services' projections, but is lower than what the Congressional Budget Office expected.

"Nearly 11.7 million Americans signed up or were re-enrolled through the marketplace as of Feb. 22," Burwell said. "We are finally moving the needle on reducing the number of uninsured."

These enrollments over the past two years have helped significantly reduce the share of Americans who are uninsured. That trend, though, is in jeopardy. The Supreme Court heard oral arguments last week in a lawsuit alleging that the Affordable Care Act doesn't permit health insurance subsidies for people living in the 34 states where the federal government is operating the Obamacare exchanges via HealthCare.gov. Almost 10 million people could lose their health coverage if the high court sides against the White House and eliminates the subsidies.

"We're confident that we will prevail in the court case argued before the Supreme Court last week. The law is clear," Burwell said Monday. "The text and structure of the Affordable Care Act demonstrate that individuals in every state are eligible for tax credits. Those who support this lawsuit believe that the law should be dismantled or repealed, and they are content to roll back the progress that we have achieved."

Among the estimated 7.7 million enrollees from the federal health insurance exchanges, 87 percent received tax credits worth $263 a month on average, Burwell said. More than half the enrollees paid $100 or less a month, including their subsidies. "These numbers show just how important the tax credits are to millions of Americans and to the insurance markets in those states and throughout the marketplace," she said.

The annual open enrollment period for people using the health insurance exchanges officially ended Feb. 15, but sign-ups have continued.

Federal officials and most state-run exchanges have allowed individuals with applications in process to complete them for about a week following the deadline. In addition, the federally managed exchanges serving more than 30 states, and the majority of the exchanges operated by 13 states and the District of Columbia, re-opened enrollment for people who learn when they file their income taxes that they owe a fine under the Affordable Care Act's individual mandate that most U.S. residents have health coverage.

The numbers Burwell announced Monday are 300,000 higher than those reported by the White House last month. Although additional tax season sign-ups are likely to boost the tally, enrollment is expected to decline over the course of the year as consumers obtain health coverage through another source, like a job, or as they give up their policies and become uninsured.

"While we know that the numbers will change as the year continues, we are pleased with the results today," Burwell said.

The number of sign-ups Burwell announced Monday doesn't reflect how many of those enrollees have begun paying for their insurance policies, which is necessary to secure coverage. During the 2014 enrollment campaign, the number of enrollees surpassed 8 million, but fell below 7 million within six months.

During the year, people can use the exchanges to buy insurance if they experience a life change, such as having a baby or getting married. Open enrollment for 2016 coverage begins Nov. 1, 2015, and runs through Jan. 31, 2016.

The health insurance exchange figures announced Monday don't include new sign-ups for Medicaid or the Children's Health Insurance Program. Nearly 11 million people have joined those programs since Obamacare enrollment began in October 2013, largely driven by the law's broadening of Medicaid eligibility. To date, 28 states and the District of Columbia have opted into the Medicaid expansion.

Huge Stakes As Supreme Court Takes Aim At Obamacare Again

Jeffrey Young   |   March 3, 2015    9:00 PM ET

WASHINGTON -- Obamacare faces its strangest challenge yet when the Supreme Court takes up the law for the third time Wednesday, but the oddity of the lawsuit shouldn’t obscure the cataclysm that a loss for President Barack Obama would provoke.

The Supreme Court case is the latest legal effort by political opponents of the Affordable Care Act to ruin Obama’s signature domestic achievement. If successful, the suit would tarnish Obama’s legacy, foment infighting among Republicans, aggravate bitter partisanship between the GOP Congress and the White House, and threaten chaos in the health insurance market. But the worst consequences would fall on the estimated 9.6 million people who would lose their health insurance.

The lawsuit, King v. Burwell, isn’t like the previous two Obamacare cases that came before the Supreme Court. Three years ago, in National Federation of Independent Business v. Sebelius, Chief Justice John Roberts joined the court’s four liberals in upholding the constitutionality of the Affordable Care Act’s individual mandate that most Americans obtain health insurance. The Supreme Court last year weakened Obamacare’s birth-control coverage rule in Hobby Lobby v. Burwell, a case with religious-freedom implications.

This time, the high court will hear oral arguments in a lawsuit engineered by conservative and libertarian think tanks that claims a handful of words deep within the Affordable Care Act -- “an exchange established by the state” -- makes it illegal for the government to issue tax credits for health insurance in more than 30 states with federal health insurance exchanges.

The plaintiffs’ picayune contention has dire implications for low- and moderate-income people receiving those subsidies in states where the federal government, not the state, created a health insurance exchange under Obamacare. Just 13 states and the District of Columbia are fully operating these marketplaces. The federal government controls 34, and three states that established exchanges later turned over enrollment to federal authorities.

As of last month, 8.8 million people had private health insurance policies obtained via the exchanges in the 37 states using the federal HealthCare.gov system, not counting millions more who used state-based marketplaces. Since sign-ups began in October 2013, the share of customers on federal exchanges receiving tax credits for their coverage has been above 85 percent. The average value of those subsidies is $268 a month, and brings down the average price to $105 for subsidized enrollees, data from the Department of Health and Human Services show.

If the Supreme Court sides with the plaintiffs when justices issue their ruling, expected in June, a majority of the public wants the subsidies restored, one way or another, according to a survey by the Henry J. Kaiser Family Foundation. The poll revealed that 64 percent of Americans believe Congress should enact a fix, and 59 percent think their own states should set up health insurance exchanges.

But a fix very well may never come. Congress could have made the Supreme Court hearing unnecessary by passing a simple amendment clarifying the intent of the Affordable Care Act, but has refused to consider one. And the Obama administration maintains there’s nothing it can do on its own to mitigate the disappearance of subsidies.

States could evade the consequences of a high court ruling against the subsidies by establishing health insurance exchanges, but Republicans control at least one branch of government in nearly all of the states that would be affected by this case, and none has taken steps to begin the contentious, time-consuming and costly effort to do so.

In Congress, a viable path for a legislative solution is difficult to envision. Recently, Republicans expressed openness to providing unspecified temporary assistance to those who lose their tax credits. Even that vague promise is couched in a plan to scrap Obamacare and reduce or undo health insurance subsidies down the line, which would jeopardize coverage for more people.

But in the five years since the Affordable Care Act became law, the GOP has failed to agree on any “replacement plan,” and it's highly uncertain leadership would even have the votes to protect the subsidies until Republicans find that consensus, if they ever can. Pressure could build once millions of their constituents find themselves in the lurch, but it will be countered by conservatives satisfied with nothing less than full repeal of Obamacare. And this internal argument would take place while Republicans are in the midst of a hotly contested presidential primary.

Wiping out the subsidies in more than 30 states would deepen the divide between the haves and have nots in the American health care system, and residents in red states, and in battleground states like Ohio and Pennsylvania, would bear the brunt.

Regions of America with smaller and shrinking shares of uninsured residents, mostly in the Northeast and on the West Coast, would sustain their progress, while those in mostly Southern states, where fewer people had health insurance before Obamacare, would regress. What’s more, federal taxpayers in generally poorer states without subsidies would underwrite health care for people in mostly richer states and get nothing in return.

Among those who would lose coverage, 62 percent live in Southern states -- mostly governed by Republicans -- 81 percent are employed and 61 percent are white, according to the Urban Institute.

The disruption wouldn’t be limited to people who qualify for health insurance subsidies. It would have profound effects on health insurance markets in the affected states. The Rand Corp. predicts 1.2 million of the 9.6 million who would become uninsured after a Supreme Court ruling against Obamacare aren’t even receiving subsidies.

That's because the parts of the Affordable Care Act requiring health insurance companies to accept customers with pre-existing conditions and the law’s mandates for basic benefits would remain, but the coverage would be unaffordable for a growing number of people over time, forcing them to drop their coverage.

Industry jargon describes the worst-case scenario as a “death spiral.” Those who can afford to pay full price would remain, but sicker people with higher health care costs would be the most likely to do so. Their medical expenses would force insurers to raise rates, making coverage too costly for even more people.

This cycle could continue until the health insurers’ customers are so unhealthy, some companies can’t afford to do business in those states anymore, and pull out, further limiting access to insurance.

No Way To Prevent Disaster If The Supreme Court Guts Obamacare, Top Official Says

Jeffrey Young   |   February 24, 2015    4:38 PM ET

The federal government is powerless to prevent millions from losing health insurance if the Supreme Court rules against President Barack Obama in a lawsuit to be argued next week, Health and Human Services Secretary Sylvia Mathews Burwell wrote in a letter to lawmakers Tuesday.

The case, King v. Burwell, alleges the Obama administration unlawfully provided subsidies to millions of residents of states that did not create health insurance exchanges under the Affordable Care Act. The federal government operates at least part of the the exchange marketplaces in 37 states. The Supreme Court will hear oral arguments next Wednesday and is expected to issue a ruling in June.

The lawsuit has enormous stakes for the estimated 10 million people who would lose their health coverage if the court decides against Obama. The exit of that many people from the insurance markets in their states also would destabilize the markets, leading to big price increases that would drive more individuals away from health coverage. People living in 14 mainly Democratic states that established health insurance exchanges would be unaffected.

Republicans, who have refused to consider legislation to amend the single clause in the law that is the subject of the challenge, have demanded the Obama administration explain how it would fix the disruption caused in states with federal exchanges, most of which are governed by the GOP.

Before Tuesday, Burwell and other officials would go no further than stating they expected to win the case. Burwell reiterated that point in her letter, but also declared she can do nothing on her own authority.

"While we are confident in our position, a decision against the administration in the King case would cause massive damage," Burwell wrote. "We know of no administrative action that could, and therefore we have no plans that would, undo the massive damage to our health care system that would be caused by an adverse decision."

With the federal government adopting the position that it can't repair that damage on its own, the likelihood of chaos reigning in two-thirds of the states' health insurance markets appears high.

Congressional Republicans repeatedly have promised plans that would "replace" Obamacare, either after a legislative repeal or a Supreme Court ruling against the law, since before Obama signed the Affordable Care Act in March 2010. But they have failed to coalesce around a policy, and have very little time to do so before a June ruling by the high court. The GOP has rejected a targeted fix to the law that would preserve the subsidies if the court decides they aren't legal.

Governors and state legislators looking to protect their residents from this disruption could do so by establishing health insurance exchanges, but none appear poised to act. At the National Governors Association meeting in Washington last weekend, Wisconsin Gov. Scott Walker (R) and others said they had no plans to take action, referring to the health insurance subsidies for millions of their constituents as a federal matter.

About 11 million people are enrolled in private coverage chosen via Obamacare's health insurance exchanges after two years of sign-ups, according to the Department of Health and Human Services. Because of those enrollments and the Affordable Care Act's expansion of Medicaid -- adopted mainly by Democratic-run states -- the rate of uninsured Americans is the lowest in at least seven years, according to Gallup.

Read Health and Human Service Secretary Sylvia Mathews Burwell's letter to Congress:

HHS Secretary Burwell Letter to Congress

Obamacare Enrollment Reopened For Taxpayers Hit By Mandate Fine

Jeffrey Young   |   February 20, 2015   10:01 AM ET

Taxpayers facing fines for not having health insurance in 2014 will get another chance to sign up for benefits on the Obamacare exchanges this year, federal officials announced Friday.

From March 15 through April 30, individuals who learn when they file tax returns that they must pay a penalty under the Affordable Care Act's individual mandate can return to HealthCare.gov to choose a plan for the current year, Andy Slavitt, the principal deputy administrator of the Centers for Medicare and Medicaid Services, told reporters on a conference call.

The three-month Obamacare sign-up campaign officially ended Sunday. But President Barack Obama's administration and some state authorities are reopening enrollment around tax time as a means of covering more uninsured people and mitigating the backlash from taxpayers who weren't covered last year and discover they owe fines starting at $95 per person when they file their 2014 returns.

This tax season is the first time Americans must account for their health insurance status when they file tax returns, and the first time anyone will have to pay a penalty for not being covered. Awareness of that penalty remains low among the uninsured, according to survey results published Thursday by the Urban Institute. As many as 6 million people will have to pay the mandate fine this year, the Treasury Department estimates.

That makes this a unique circumstance, not a signal that future enrollment deadlines will be so flexible, Slavitt said.

"Our intention is that this is one year only for people who have not been in the communication loop around the tax penalty and whose first time learning of it will be filling out their taxes this year. So this is really a one-year-only special enrollment period," Slavitt said.

The "special enrollment period" announced Friday applies to residents of the 37 states where the federal government operates the health insurance exchanges. The state-run exchanges in Minnesota, Vermont and Washington previously established a second sign-up period for people who owe the Obamacare mandate fine. California also announced a special enrollment period Friday, as did New York, which will accept new enrollees from March 1 to April 30. Other states may do the same, including Connecticut, Idaho and Kentucky.

Not everyone who failed to sign up by the Feb. 15 deadline is eligible for the new enrollment opportunity. Those who qualify must not have health insurance, must already have filed their taxes and paid the mandate penalty for 2014 and must attest they only learned about the fine after Sunday's insurance sign-up deadline, Slavitt said. Individuals who enroll during the upcoming period will still owe the penalty for last year unless they qualify for an exemption. These individuals also may still have to pay a partial penalty when they file their 2015 taxes because the Affordable Care Act requires people to have health coverage for at least nine months a year.

The Centers for Medicare and Medicaid Services also announced Friday the availability of a tool on HealthCare.gov designed to simplify the process of determining whether an individual is exempt from the individual mandate.

Health and Human Services Secretary Sylvia Mathews Burwell revealed less than a week ago that she was considering restarting enrollment for people subject to the mandate penalty. A group of congressional Democrats and organizations like Families USA that support Obamacare had urged her to make these allowances for taxpayers in that situation.

"There remain millions of people who are unaware of the premium subsidies that make insurance affordable and who didn’t know about the tax penalty for failing to buy insurance. This special enrollment period will therefore be a helpful, teachable moment and will enable many people to obtain health coverage and avoid future penalties,” Families USA Executive Director Ron Pollack said in a press release.

Federal officials also disclosed Friday that many of the tax forms sent to Obamacare enrollees contain errors. People enrolled in health insurance plans began receiving so-called 1095-A forms last month, which are needed when filing taxes to ensure households received the correct subsidy amount for their insurance. When a taxpayer's income is higher than reported to the health insurance exchange, he or she may have to repay at least a portion of the tax credits received for a health plan, while those whose income was lower than reported may receive a larger tax refund.

The federal government sent incorrect forms to about 20 percent of individuals who bought health insurance through the federally run health insurance exchanges, or 800,000 people, Slavitt said. Starting today, those households will be notified of the mistake and provided with corrected tax forms. About 50,000 of those people already have filed their taxes and will contacted by the Treasury Department about rectifying the issue. States including California and Nevada also provided inaccurate 1095-A forms to residents. And problems with these tax documents in Connecticut delayed delivery to health insurance customers.

This story has been updated to note that California and New York will also reopen enrollment.