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Jeffrey Young   |   March 8, 2016    3:54 PM ET


WASHINGTON -- Kentucky has turned into the place where Obamacare repeal rhetoric meets Obamacare repeal reality. Reality is winning.


Gov. Matt Bevin (R) made his name in Bluegrass State politics as a tea party outsider, and throwing out the Affordable Care Act was one of his most common refrains. He used it first during his unsuccessful primary challenge against Sen. Mitch McConnell, now majority leader, in 2014, and then in his winning bid for the top position in the state last year.


But a funny thing happened on the way to the governor's office: Bevin's anti-Obamacare rhetoric started to tone down as Election Day approached. And in the months since he's been chief executive of Kentucky, instead of ripping up Obamacare out of his state, Bevin is making alterations to how the law works there and leaving its core elements and benefits in place.


A candidate who vowed to completely roll back Kentucky's expansion of Medicaid to more than 300,000 poor residents under the Affordable Care Act now is a governor who plans to put some conservative window dressing on the program, akin to what Gov. Mike Pence (R) did in Indiana. And rather than totally eradicate the state's health insurance exchange, Kynect, Bevin now plans to leave big parts of it in place even while sending its more than 100,000 customers to HealthCare.gov to buy their coverage instead.


That's quite a turnaround for a man who used to say stuff like this all the time:










There's a lesson here for would-be Obamacare repealers.


Six years after President Barack Obama enacted the Affordable Care Act, the law has extended health coverage to an estimated 20 million people and driven the uninsured rate to a historic low, and the health insurance industry and other players in the private health care sector have adapted to the law, however awkwardly.


Bevin seems to have learned firsthand that it was impossible to snap his fingers and make all that go away without upsetting a lot of people. 


In other words, when Republicans have had chances to put their repeal talk into action, they haven't.


That hasn't stopped the GOP-led Congress and Republican presidential candidates from clamoring for repeal -- or from making vague pronouncements about "replacing" Obamacare with something or other, even though it's not possible to achieve the Affordable Care Act goal of expanding coverage using the policies typically espoused by Republicans.





For all the bluster about Obamacare in Congress and on the campaign trail -- plus the many, many repeal votes -- state-level Republicans have had more opportunity to actually disrupt the Affordable Care Act.


For starters, there are still 20 states that refuse to expand Medicaid using federal money provided by the law, and two-thirds of states declined to establish health insurance exchanges, leaving the work to federal authorities.


Moreover, states like Florida and Texas enacted laws making it harder for insurance counselors to advise consumers. And many GOP-led states joined in on lawsuits that threatened to fell the Affordable Care Act at the Supreme Court.


But undoing Obamacare benefits that already exist is another matter entirely.


Bevin isn't doing it. Neither did Arkansas Gov. Asa Hutchinson (R), who succeeded a Democrat in 2014 and is negotiating with the state's GOP legislature to extend the expansion there.


Illinois, Maryland and Massachusetts also welcomed new Republican governors last year who followed Democrats, and scrapping Medicaid expansion hasn't been up for discussion in those states. Arizona Gov. Doug Ducey (R) hasn't moved to undo the expansion implemented by his Republican predecessor, Jan Brewer, either.

Bevin, by the way, wanted to disrupt Obamacare in Kentucky despite its extraordinary success.

Only Arkansas saw a bigger decline in its uninsured rate among the states, as Kentucky went from 20.4 percent of residents without health insurance in 2013 to 7.5 percent in 2015, according to Gallup. And keeping the Medicaid expansion and Kynect have been popular in surveys, even though Kentuckians think poorly of the Affordable Care Act itself.

Maybe that helps explain what Bevin actually proposes to do now. On Medicaid, Bevin has talked about requiring beneficiaries to pay more for their care, not taking their coverage away from them.

And even though the Kynect brand name and website are being made sacrifices at the altar of anti-Obamacarism, Kentucky will continue to have a health insurance exchange that oversees insurers and handles other functions, following a model already adopted by Hawaii, New Mexico, Nevada and Oregon.

If that's the worst a tea party Republican ushered into office by a wide margin in a conservative state can do to Obamacare, maybe supporters of the Affordable Care Act don't have that much to worry about. And maybe those eager about repealing the law should steel themselves for more disappointment.

Jeffrey Young   |   February 4, 2016    2:02 PM ET


WASHINGTON -- Close to 13 million people enrolled into private health insurance plans via the Affordable Care Act's exchange marketplaces, Health and Human Services Secretary Sylvia Burwell announced Thursday.


The sign-up period closed Sunday, and by the end, 12.7 million individuals had chosen plans through HealthCare.gov and the 13 state-run exchanges, Burwell said on a conference call with reporters.


"Open enrollment for 2016 is over and we are happy to report it was a success," Burwell said. "It's clear that marketplace coverage is a product that people do want and need."


The results made public Thursday show that sign-ups met the federal government's expectations for the year. Prior to the beginning of this open enrollment period last fall, Health and Human Services projected that 11 million to 14.1 million people would select health insurance plans on the exchanges by Feb. 1. The department predicts about 10 million people will have this type of coverage by the end of the year, as some consumers drop their plans either to switch to other forms of benefits, like from a job or Medicare, or to become uninsured.


HealthCare.gov CEO Kevin Counihan was ebullient when describing his view of the 2016 open enrollment period.


"I'll just be blunt with you. We knocked the lights out this year. We did a great job," Counihan said during the conference call. "Is it perfect? No. Do we have more to do? You bet. But it's been a great year."


The 38 states using HealthCare.gov represented 9.6 million of the 2016 enrollments, and more than 4 million of those customers are new to the exchanges, Burwell said. The remainder came from state-run exchanges in places including California, Colorado, Minnesota and Washington state that separately announced 2016 enrollment figures this week, and also reported growth. HHS will release a more detailed demographic report within weeks. The total doesn't include more than 400,000 people who enrolled in the Basic Health Plan, a program for low-income families, in New York and Minnesota.


Obamacare remains a political hot potato, with more Americans opposing the law than supporting it, according to survey data released by the Henry J. Kaiser Family Foundation last week. Republicans in Congress continue attempting to scrap the ACA, including a vote Wednesday that unsuccessfully attempted to override President Barack Obama's veto of a bill to repeal most of the law. And the Republicans running for president each call for its eradication.



The Department of Health and Human Services estimates 17.6 million more people were covered as of the third quarter of 2015 than at the end of 2013.

But measured by its performance expanding health coverage to Americans who previously lacked it, Obamacare is working. Since health insurance plans from these exchanges and coverage from expanded Medicaid took effect at the beginning of 2014, the uninsured rate sharply dropped. The Department of Health and Human Services estimates 17.6 million more people were covered as of the third quarter of 2015 than at the end of 2013.

Heading into the enrollment period that began Nov. 15, the Obama administration sought to tamp down expectations for growth on the exchanges. In September, Burwell cautioned that continued progress expanding the marketplaces' reach and further reducing the ranks of the uninsured would prove difficult because the people who needed the coverage the most or qualified for the most generous financial assistance already had signed up.

There were other reasons to believe the exchanges wouldn't be able to attract and retain large numbers of customers. Health insurance companies implemented bigger price hikes for 2016 than for the year before, citing higher-than-expected medical costs from those who'd signed up. This elevated concerns that the coverage would be unaffordable, especially for those eligible for low or no tax credits to defray the cost. And although the minimum penalty for failing to get covered rose from $95 in 2014 to $325 in 2015 to $695 this year, the newness of the individual mandate and the higher prices for insurance were reasons to doubt the policy would be effective at encouraging people to sign up. 

Over the course of 2015 and into this year, health insurance companies like UnitedHealth Group, Aetna and Anthem cautioned they were losing money or making only modest profits in this part of the market, heightening concern that too few healthy consumers were getting covered and contributing premiums to offset the costs of sicker customers.

This matters because the exchanges can't work if health insurance companies can't make a profit on them. So far, that's been a problem. And although the exchanges aren't on the verge of collapse, as Republicans insist, it's still an open question whether they will be viable over time.

The first two years showed significant attrition from the marketplaces as consumers left the exchanges. Last year, 11.7 million people had signed up by the end of open enrollment in February, but the total declined to 9.3 million in September.

The difference between the 12.7 million tally announced Thursday and the count later in 2016 is likely to be smaller. The administration is more accurately counting in real time how many people enrolled but canceled or were terminated by insurers because they didn't pay the premium.

No matter what happens, exchange enrollment won't be anywhere near the 21 million the Congressional Budget Office predicted as recently as last March. Last week, the CBO significantly downgraded its projections and now expects exchange enrollment to be 13 million in 2016. Mostly, the budget agency recognized it was wrong about two key things. The CBO expected more employers to drop health benefits, which didn't happen, and it didn't anticipate how many people would continue buying coverage directly from insurers instead of using the exchanges.

Also on HuffPost:

Jeffrey Young   |   December 9, 2015    5:20 PM ET

WASHINGTON -- Republican presidential candidate Ben Carson unveiled his agenda to reform the American health care system Wednesday.

What does the renowned pediatric neurosurgeon have to offer to the debate? First and most importantly, this magnificent photo on the cover of his plan.

Prescriptions, empowerment, healing, inspiration and revival are things anyone can get behind!

There's some other stuff, too. Carson would repeal Obamacare (natch) because of problems with the Affordable Care Act, like it doesn't have enough freedom in it. He also would sort-of-but-not-really get rid of Medicare and Medicaid, at least in the sense that those programs have always been understood.

The centerpiece of Carson's vision for the future of American health care is what he calls Health Empowerment Accounts, which seem a lot like the already existing health savings accounts that people -- even ones on Obamacare! -- can use to sock away cash tax-free for future health expenses. Also like health savings accounts, Carson's Health Empowerment Accounts would be paired with high-deductible health insurance plans. Everyone would get a Health Empowerment Account when they get Social Security numbers, which make them different from health savings accounts.

Based on a close reading of the document released by Carson's campaign, Health Empowerment Accounts also would seem to feature more Empowerment than the health savings accounts available on the market today.

So in place of Obamacare, which includes all sorts of rules about who health insurance companies have to sell policies to (everyone) and what kinds of benefits they have to cover (lots 0f them), Carson's plan would allow people to open tax-free savings accounts (which they already can) to put away money (which they probably don't have) to pay for medical care until their insurance deductible is met (which it probably won't be).

Medicare beneficiaries also would gain access to more liberty under Carson's plan, which would free (force) people to wait until they're 70 get on the program, cap the amount the government pays for the their coverage and leave them liberated to pay the difference. They, too, would gain the inalienable right to have a Health Empowerment Account they can put money into if they have any money.

Carson doesn't forget about Medicaid, the joint federal-state health program for the poor. The federal government would patriotically limit its funding to states, permit poor people to buy the same unregulated health insurance plans as their wealthier neighbors and compassionately throw them a little money to put in Health Empowerment Accounts they can try to use for the stuff their new insurance won't cover.

Prognosis: Utopia!

Also on HuffPost:

Jeffrey Young   |   November 17, 2015   10:36 AM ET


WASHINGTON -- Health insurance consumers who use HealthCare.gov to buy their plans can choose to stick with what they have and let the system automatically renew their coverage for next year. A new report suggests that just might be a bad idea.


That's because the best deals for this year aren't necessarily the best deals for 2016, according to a Henry J. Kaiser Family Foundation analysis. In almost three-quarters of the counties across more than 30 states that use the federal HealthCare.gov system to apply, the lowest-price "silver" insurance plan is a different policy, and maybe even from a different insurer, than it was last year. For a 40-year-old, that could mean the difference between paying 15 percent more and 7 percent more next year, on average.


The third year of health insurance enrollment on the exchanges created by the Affordable Care Act began Nov. 1 and runs until Jan. 31, and there's been a lot of changes in the plans available and their premiums. Across the country, rates on these marketplaces are going up an average 7.5 percent compared to this year. Some insurers instituted huge increases, while others actually reduced their prices.


The cheapest silver plan is different in 73 percent of counties in HealthCare.gov states than it was for the 2015 sign-up period. The Kaiser Family Foundation looked at these mid-level plans because they're the most popular compared to bronze, gold and platinum plans and the bare-bones "catastrophic" plans available to people under 30. Nationally, more than two-thirds of those who signed up for insurance through the federal exchanges or those run by states like California and Colorado selected silver plans during open enrollment for 2015.


HealthCare.gov customers will be automatically renewed into their current plans -- if they are still available -- on Dec. 15, although they can change to other policies until the end of open enrollment.

There's one big potential trade-off to bargain hunting, however. Consumers who give up their current policies and sign up for a new plan to spend less money may lose access to the doctors, hospitals and other medical providers or prescription drugs covered by their existing insurance plan. And price isn't the only factor to consider, because insurers structure deductibles and cost-sharing requirements for services and medicines differently.

Health insurance marketplace customers faced a similar dynamic a year ago. Exchange officials and consumer groups urged policyholders to look for alternatives that saved money, and the campaign was partially successful: Slightly more than half of returning customers actively shopped for plans rather than allowing automatic re-enrollment to take effect, which was more than experts expected.

This year, the stakes may be higher, and not just for the consumers themselves. Premiums are rising faster than they did last time around, leading to concerns that coverage won't be affordable. Exchange enrollment declined over the course of this year, and federal officials expect it to grow slowly during this sign-up period, so encouraging current enrollees to find plans at prices they can manage could be key to making these still-new marketplaces thrive.

By automatically renewing or by actively keeping the same plan for next year, a 40-year-old would pay $304, on average, per month, not including any tax credits that reduce the cost, which is a 15 percent increase from this year's average price. But by switching to the lowest-cost silver plan for 2016, the cost would be $283 a month without subsidies, which is 7 percent higher than the price of the cheapest silver policy this year, according to the report.

The Kaiser Family Foundation analysis uses a 40-year-old as an example, but premiums vary by age, so younger and older people would see different prices. Prices also are based on geographic location.

And the actual cost varies a lot by income, because there are tax credit subsidies available to people who earn between the federal poverty level -- about $12,000 for a single person -- and four times that amount.

The price subsidized enrollees pay is based on a percentage of their incomes and on the premium for the "benchmark" plan, which is the second-lowest-cost silver policy in their local markets. The value of the credit is smaller for those on the higher end of that income scale, who also must pay a larger share of their earnings on the insurance. Eighty-seven percent of those who signed up during the 2015 enrollment period received these tax credits. People with incomes below 250 percent of poverty also must choose a silver plan to qualify for extra subsidies that reduce their deductibles and other out-of-pocket costs, which the majority of enrollees get.

Also on HuffPost:

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.

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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.

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