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The latest news on Obamacare from Business Insider

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    obamacare protest supreme court

    More than half of the 2014-2015 enrollment period for the Affordable Care Act, best known as Obamacare, is in the books, and the enrollment figures on the surface look very encouraging.

    To be clear, Obamacare is about more than just enrollment figures. For one thing, in order for the health reform law to be successful, it'll need people that enroll to actually continue paying their premium.

    This is the only way that medical care costs get spread out over a greater swath of the public, which is needed to control medical care cost inflation.

    However, between April and mid-October, for instance, around 1 million people stopped paying for their health insurance. The program will need to minimize this attrition in 2015 and beyond in order to be successful.

    Surface enrollment data is strong

    In the meantime, Obamacare enrollments from week six (Dec. 20 to Dec. 26) continue to point toward the law bringing in more than the 9.1 million people that the Department of Health and Human Services had predicted.

    Based on data for just the 37 states operating under the federally run, nearly 6.5 million people have selected plans. During week six just 96,446 people selected a plan, but this drop-off was expected considering both the holiday week and the fact that we're past the deadline whereby people could enroll and still be covered by Jan. 1, 2015. This deadline was a huge impetus to the enrollment surge witnessed in weeks four and five.

    In spite of the subdued enrollment in week six, nearly 317,000 people window-shopped healthcare plans on and close to 1.4 million users were active on the site. The implication is that interest in obtaining health insurance is still high for many uninsured Americans. 

    Things are going well numbers-wise at the state level, too. Through mid-December some 1.1 million plan selections had been made, bringing the total number of selected plans through all 50 states to at least 7.6 million.

    Here's a figure to worry about

    Yet fresh data from the HHS tells us that 5.6 million Obamacare enrollees and also investors have something to seriously worry about.

    In a press release dated Dec. 30 the HHS announced that a whopping 87% of people enrolled through (5.6 million people) between Nov. 15, 2014, and Dec. 15, 2014, were getting financial assistance, also known as a subsidy. This is up from the 80% of enrollees who received a subsidy in the Nov. 15, 2013, to Dec. 15, 2013, period.

    There are some positive takeaways from this figure. First, I'd suggest that fully functional software is making it easier for those who are eligible to receive a subsidy to enroll in the 2014-2015 period than in the prior enrollment period which was filled with glitches. Also, these subsidies act as a dangling carrot, encouraging people to enroll.

    However, this seven percentage point rise in enrollees qualifying for subsidies could be a potential death knell for Obamacare based on a Supreme Court case expected to be ruled on sometime in June. Plaintiffs in the case argue that the language of the ACA is structured in such a way that only states running their own exchanges can divvy out subsidies to eligible individuals.

    Thus, if the Supreme Court finds in favor of the plaintiffs, it would mean that the 5.6 million people currently receiving subsidies via, the federally run exchange, would no longer receive those payments. I believe very, very few of those enrollees currently receiving a subsidy could afford healthcare without federal assistance.

    The obvious solution is that states would need to build their own exchanges, however this is a task that would take one to two years to complete. I'm not certain that Obamacare could survive such a shock.

    Very uncertain times

    To say the least, these are very uncertain times for health-benefits providers. Just as Obamacare has relied on subsidies to lower the rate of uninsured individuals, some insurers have geared their enrollment game plan around attracting these government-sponsored members. Redacting these subsidies now could be unpleasant for insurers' bottom-lines.

    Let's discuss three different ways an investor could approach this critical decision in June. One way is, of course, to avoid the situation altogether. But, if you do, you could run the risk of missing out on big gains in the insurance sector in the meantime and following the Supreme Court's decision.

    Your second option is to can focus on national insurers that have minimal exposure to Obamacare. In this instance, "minimal" exposure could simply mean insurers that have a balanced portfolio of products and which receive only a small amount of premium payments from Obamacare. 

    UnitedHealth Group, the nation's largest insurer, for instance, receives a quarter of its revenue from Medicare Advantage plans and nets a good chunk as well from its health management service company Optum. This isn't to say an unfavorable ruling wouldn't affect UnitedHealth, but comparably speaking it would be in better shape than many of its smaller peers.

    Lastly, you can choose to angle your investment strategy on insurers that operate in states that have their own exchange. While it's unlikely you're going to find any that operate solely in those states, some net a higher percentage of their Obamacare enrollees from states with their own exchanges than others. 

    Molina Healthcare, for example, generates a good number of enrollees from California, which operates its own exchange. Not to mention, Molina only recently dipped its toes into the water when it comes to operating in the individual insurance market. Losing a few thousand members wouldn't dramatically impact its bottom line.

    One thing is for certain: it's going to be pins and needles for Obamacare, insurers, investors, and 5.6 million people receiving subsidies via until June.

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    wellness reuters graphic png

    NEW YORK (Reuters) - U.S. companies are increasingly penalizing workers who decline to join "wellness" programs, embracing an element of President Barack Obama's healthcare law that has raised questions about fairness in the workplace.

    Beginning in 2014, the law known as Obamacare raised the financial incentives that employers are allowed to offer workers for participating in workplace wellness programs and achieving results. The incentives, which big business lobbied for, can be either rewards or penalties - up to 30 percent of health insurance premiums, deductibles, and other costs, and even more if the programs target smoking.

    Among the two-thirds of large companies using such incentives to encourage participation, almost a quarter are imposing financial penalties on those who opt-out, according to a survey by the National Business Group on Health and benefits consultant Towers Watson (see graphic at right).

    For some companies, however, just signing up for a wellness program isn't enough. They're linking financial incentives to specific goals such as losing weight, reducing cholesterol, or keeping blood glucose under control. The number of businesses imposing such outcomes-based wellness plans is expected to double this year to 46 percent, the survey found.

    "Wellness-or-else is the trend," said workplace consultant Jon Robison of Salveo Partners.

    Incentives typically take the form of cash payments or reductions in employee deductibles. Penalties include higher premiums and lower company contributions for out-of-pocket health costs.

    Financial incentives, many companies say, are critical to encouraging workers to participate in wellness programs, which executives believe will save money in the long run.

    "Employers are carrying a major burden of healthcare in this country and are trying to do the right thing," said Stephanie Pronk, a vice president at benefits consultant Aon Hewitt. "They need to improve employees' health so they can lead productive lives at home and at work, but also to control their healthcare costs."

    But there is almost no evidence that workplace wellness programs significantly reduce those costs. That's why the financial penalties are so important to companies, critics and researchers say. They boost corporate profits by levying fines that outweigh any savings from wellness programs.

    "There seems little question that you can make wellness programs save money with high enough penalties that essentially shift more healthcare costs to workers," said health policy expert Larry Levitt of the Kaiser Family Foundation.

    weights at desk

    Four-Figure Penalties

    At Honeywell International, for instance, employees who decline company-specified medical screenings pay $500 more a year in premiums and lose out on a company contribution of $250 to $1,500 a year (depending on salary and spousal coverage) to defray out-of-pocket costs.

    Kevin Covert, deputy general counsel for human resources, acknowledged it was too soon to tell if Honeywell's wellness and incentive programs reduce medical spending. But it is clear that the company is benefiting financially from the penalties. Slightly more than 10 percent of the company's U.S. employees, or roughly 5,000, did not participate, resulting in savings of hundreds of thousands of dollars.

    Last year, Honeywell was sued over its wellness program by the Equal Employment Opportunity Commission. The EEOC argued that requiring workers to answer personal questions in the health questionnaire - including if they ever feel depressed and whether they've been diagnosed with a long list of illnesses - can violate federal law if they involve disabilities, as these examples do. And, if answering is not voluntary.

    "Financial incentives and disincentives may make the programs involuntary" and thus illegal, said Chris Kuczynski, an assistant legal counsel at the EEOC.

    Using the same argument, the EEOC also sued Wisconsin-based Orion Energy Systems, where an employee who declined to undergo screening by clinic workers the company hired was told she would have to pay the full $5,000 annual insurance premium.

    medicare doctor old woman patient

    Sick? Pay More.

    Some vendors that run workplace wellness for large employers promote their programs by promising to shift costs to "higher utilizers" of health care services, according to a recent analysis by Lorin Volk and Sabrina Corlette of Georgetown University Health Policy Institute - and by making workers "earn" contributions to their healthcare plans that were once automatic.

    Consider Jill, who asked that her name not be used for fear of retaliation from the company. A few years ago, her employer, Lockheed Martin, provided hundreds of dollars per year to each worker to help defray insurance deductibles. Since it implemented its new wellness program, workers must now earn that contribution by, among other things, quitting smoking (something non-smokers can't do) and racking up steps on a company-supplied pedometer.

    "Basically, if you don't participate in these programs, you have to pay something like $1,000 out of pocket for healthcare before insurance kicks in," said Jill.

    Companies insist the penalties are not intended to be money-makers, but to encourage workers to improve their health and thereby avoid serious, and expensive, illness.

    As evidence of that, said Honeywell's Covert, the company offers employees "easy ways to get out of" some of the wellness requirements, such as certifying that they do not smoke rather than submitting to a blood test.

    pills money drugs

    Balancing The Wellness Books

    Why are companies so keen on such plans?

    Most large employers are self-insured, meaning they pay medical claims out of revenue. As a result, wellness penalties also accrue to the bottom line.

    About 95 percent of large U.S. employers offer workplace wellness programs. The programs cost around $100 to $300 per worker per year, but generally save far less than that in medical costs. A 2013 analysis by the RAND think tank commissioned by Congress found that annual healthcare spending for program participants was $25 to $40 lower than for non-participants over five years.

    Yet at most large companies that impose penalties for not participating in workplace wellness, the amount is $500 or more, according to a 2014 survey by the Kaiser foundation.

    "For economic reasons, most employers would prefer collecting the penalties," said Al Lewis, a wellness-outcomes consultant and co-author of the 2014 book "Surviving Workplace Wellness."

    Lori, for instance, an employee at Pittsburgh-based health insurer Highmark, is paying $4,200 a year more for her family benefits because she declined to answer a health questionnaire or submit to company-run screenings for smoking, blood glucose, cholesterol, and blood pressure. She is concerned about the privacy of the online questionnaire, she said, and resents being told by her employer how to stay healthy.

    Highmark vice president Anna Silberman, though, doesn't see it that way. She said the premium reductions that participants get "are a very powerful incentive for driving behavior," and that "people deserve to be rewarded for both effort and outcomes."

    (Reporting by Sharon Begley. Editor: Michele Gershberg and Hank Gilman)

    SEE ALSO: Insurers Are Quietly Raising Costs On Hundreds Of Obamacare Plans

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    Julian Gomez (R) explains Obamacare to people at a health insurance enrolment event in Commerce, California March 31, 2014.  REUTERS/Lucy Nicholson

    SAN FRANCISCO / WASHINGTON (Reuters) - U.S. healthcare executives say Obamacare is likely here to stay, despite repeated calls from Republican lawmakers for repeal of the 2010 law aimed at providing health coverage for millions of uninsured Americans.

    Top executives who gathered in San Francisco this week for the annual J.P. Morgan Healthcare conference, say that while President Obama's signature domestic policy achievement may well be tweaked, it is too entrenched to be removed.

    The Obama administration said in November that it aims to have over 9 million people enrolled in government-backed federal and state health insurance marketplaces in 2015, their second year of operation. Another 10 million have enrolled for coverage under an expansion of the Medicaid program for the poor.

    Opponents of the law in the newly-elected Congress, now dominated by Republicans, seek to replace Obama’s Affordable Care Act with their own healthcare reforms. Some are betting that the U.S. Supreme Court strikes down the federal tax subsidies helping the uninsured buy coverage in 36 states.

    For private health insurers and hospitals, the addition of millions of new covered patients has helped buoy their profits. Drugmakers have benefited from the increase in the number of patients eligible for reimbursement of prescription medications.

    Repeal of the Affordable Care Act "is not a possibility," George Scangos, chief executive officer at biotechnology company Biogen Idec Inc, said in an interview. "They would somehow have to explain to millions of people that they will lose health insurance."

    Aetna Inc, the third biggest health insurer, said it is talking to Republicans and Democrats about a possible "grand bargain" to salvage Obamacare if the Supreme Court up-ends the healthcare law later this year.

    "Blowing up the (Affordable Care Act) is like shutting down the government," Aetna Chief Executive Officer Mark Bertolini told a small group of investors. "So we are having conversations on both sides of the aisle about what ... things you change in the ACA, what we could introduce, about how to make a grand bargain should the Supreme Court decide."

    obamacare protest supreme court


    The Supreme Court is due on March 4 to hear oral arguments in the case, with a ruling expected in June.

    "We're working on a proposal to lay out the transition, to make sure we can deal with this effectively and quickly," said Senator John Barrasso, chairman of the Senate Republican Policy Committee.

    "Putting aside the Supreme Court challenge, I don't see a veto-proof majority" in Congress to overturn the law, said Merck & Co Inc Chief Executive Officer Kenneth Frazier. "I would expect changes in the structure of the law, not a wholesale repeal." 

    Some key changes Republicans are expected to target include Obamacare’s employer mandate, which requires businesses with at least 50 full-time workers to offer health coverage to their employees or pay a penalty, according to congressional aides and lawmakers.

    Republican lawmakers also want to change the law's definition of "full time" as any employee who works 30 hours a week or more, provisions that compensate health insurers for market losses and an excise tax on medical devices, including the machines that produce CAT scans and magnetic resonance images.

    The strategy around replacing Obamacare was expected to be a topic this week during a meeting of Republican leadership in Pennsylvania, congressional aides said.

    Sylvia Burwell, Secretary of the U.S. Department of Health and Human Services, which oversees the law’s implementation, said that Republican efforts to replace Obamacare are happening “despite increasing evidence that the law is working.”

    A Gallup survey showed that the percentage of Americans without health insurance fell 4.2 percentage points to just under 13 percent at the end of 2014.

    "I don't think it will go away," said Jean-Jacques Bienaimé, Chief Executive Officer at BioMarin Pharmaceutical Inc. "There will probably be some adjustments." He said the ACA has helped companies like BioMarin that specialize in drugs for rare diseases because it prohibits lifetime caps on reimbursement, even for expensive medications.

    (Additional reporting by Caroline Humer; Editing by Michele Gershberg, Bernard Orr)

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    Marilyn Tavenner

    Medicare chief Marilyn Tavenner — who oversaw the rocky rollout of the president's health care law — says she's stepping down at the end of February.

    In an email Friday to staff at the Centers for Medicare and Medicaid Services, Tavenner says she's leaving with "sadness and mixed emotions."

    Tavenner survived the 2013 technology meltdown of, but was embarrassed last fall when she testified to Congress that 7.3 million people were enrolled for coverage.

    That turned out to be an overcount that exaggerated the total by about 400,000.

    Calling Tavenner "one of our most esteemed and accomplished colleagues," Health and Human Services Secretary Sylvia M. Burwell said the decision to leave was Tavenner's.

    Principal deputy administrator Andy Slavitt will take over as acting administrator.

    SEE ALSO: 5.6M Obamacare Enrollees Could Lose Their Health Insurance

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    Ted Cruz

    WASHINGTON (AP) — Republicans running Congress have promised to use every weapon in their arsenal to take down President Barack Obama's health care law.

    But now some are questioning whether to use the congressional budget process to derail the 2010 law or save the special step for more traditional purposes like cutting spending or overhauling the tax code. A potentially divisive debate between tea party forces and GOP pragmatists looms.

    At issue is an arcane process known as budget reconciliation. It's the only filibuster-proof option available to Republicans, who control the Senate with 54 seats but must still muster 60 votes to pass other legislation.

    Senate precedents limit the number of reconciliation bills — one for taxes, one for spending and one to raise the government's borrowing cap — and so a major debate has begun among Republicans over what to put in it.Hard-line conservatives want to use the process to force a showdown with Obama over the law.

    Sen. Ted Cruz, R-Texas, told a Heritage Foundation gathering of conservatives last week that Republicans should "use every procedural tool available, including reconciliation, to repeal Obamacare with 51 votes in the Senate."

    That's a view shared by conservative groups like the Senate Conservatives Fund and Heritage Action, and prominent voices on the right like Erick Erickson, publisher of the conservative blog.

    "It's time to stop pussy-footing around with excuses and half-assed attempts at partial repeal, and get serious," Erickson wrote last week. "Make Obama veto the repeal of his signature legislation."

    Pragmatic voices in the GOP, however, say the certainty of an Obama veto effectively means that Republicans would be wasting the opportunity given them under special budget rules that limit debate and can guarantee delivery of legislation to Obama.

    "I'd like to get tax reform done. I think we could do infrastructure in that process. And I think that's something that could actually get enacted," said Sen. John Thune, R-S.D., chairman of the Senate Commerce committee. "I mean we're going to have a lot of Obamacare votes one way or the other."

    A reconciliation measure can only advance after the House and Senate have agreed upon a measure called a budget resolution, which sets broad parameters for spending, revenues and curbs to benefit programs such as Medicare and Medicaid.

    Democrats used reconciliation to help pass Obama's health care plan. And Bill Clinton and Republicans controlling Congress used it in 1997 to advance a balanced budget bill. Republicans, led by Newt Gingrich in 1995, tried to use it to pass a bitterly partisan 1995 balanced budget plan Clinton vetoed. Even though their budget resolution is likely to project a balanced federal ledger over the coming 10 years, Republicans are signaling they're not willing to do a party-line replay of their 1995 experience.

    "The only way to do entitlement eligibility changes is on a bipartisan basis," Senate Majority Leader Mitch McConnell, R-Ky., said Thursday at a news conference at a GOP issues retreat in Hershey, Pa. "We do not intend to be offering unilateral, one party-only entitlement eligibility changes."

    Republicans devoted a session at the retreat to the topic of reconciliation. A decision on what to do with it appears a ways off.

    "At some point we'll decide if we're going to have reconciliation and if we do, we'll make some decision much later on," House Speaker John Boehner told reporters last week.

    The view of some pragmatists is that reconciliation should be used to get a result that might get signed into law or as leverage to make Obama more uncomfortable than he would be in vetoing an Obamacare repeal measure. And some lawmakers think that an upcoming Supreme Court ruling could unravel much of the law, making them wary of wasting reconciliation on the health care law.

    "It should be things like that that actually improve the long-term fiscal stability of the country and maybe provide us some revenues for things where we can agree, like infrastructure," said Rep. Tom Cole, R-Okla.

    A telling episode last fall illustrates the passion over the issue.

    McConnell told Fox News that repealing Obama's health care plan would "take 60 votes in the Senate .... and it would take a presidential signature." This sparked a mini-eruption on the right that prompted McConnell's office to release a statement promising to use budget reconciliation to repeal the law.

     This article was written by Andrew Taylor from The Associated Press and was legally licensed through the NewsCred publisher network.

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    A ruling in the looming case King v. Burwell could wipe out health insurance subsidies for some 3 million Americans in a dozen states that could decide the 2016 election and rely on the federal exchange, according to new research by professors Theda Skocpol of Harvard University and Lawrence R. Jacobs of the University of Minnesota.

    In Florida, nearly 1.2 million Americans are enrolled in a federal exchange plan as of early 2015. In Ohio, Virginia, Pennsylvania, New Hampshire and North Carolina a total of 1.3 million Americans would lose their plans. Notably, in each of those states the number of federal exchange customers who risk becoming ineligible for subsidies exceeded the 2012 presidential election winner's margin of victory in that state, Skocpol and Jacobs found.

    "These are middle income people — making between around $30,000 and $80,000. A lot of them around the median income depend pretty heavily on the subsidies. Many of them are Republican voters," Skocpol said. "And they're not as easily ignored by Republicans as poor people are."

    The chart below was made by Skocpol and Jacobs:TPM Scotus

    A few caveats. Not every exchange customer receives the premium tax credits but most do — the subsidies cover 76 percent of premiums on average, available to Americans between 133 percent and 400 percent of the federal poverty level. The enrollment numbers could also change between now and June 2015, by when the Supreme Court is expected to issue its ruling.

    If the justices scrap the subsidies, Democrats would quickly start banging the drum for fixes. In theory the impact of a Supreme Court ruling can be mooted if every state builds its own "state-based" exchange — the subsidies then wouldn't be restricted for anyone who's currently eligible. But GOP governors and lawmakers are likely to face enormous political pressure from conservatives to resist any fixes, putting them between their base and their constituents.

    "We actually think this will create enormous problems first and foremost for Republican governors and for Republicans in Congress," Skocpol said.

    Ohio, Wisconsin, and North Carolina have Republican governors. Pennsylvania, Virginia, and New Hampshire have Democratic governors who face Republican legislatures that could block efforts to build state-run exchanges. Governors in Ohio, Iowa, Nevada and Michigan have already expanded Medicaid for low-income residents. They risk facing an unenviable situation where the poor are subsidized but residents earning slightly more are not.Scott Walker

    Ironically, the negative consequences of a Supreme Court ruling to restrict the subsidies would be most prevalent in Republican-heavy states, which overwhelmingly refused to build their own exchanges. The 18 states that built their own exchanges lean Democrat or are divided, with the exception of Idaho — they would be unaffected by a Supreme Court decision.

    In Congress, Republicans would be hard-pressed to support any improvements to counteract a potential Supreme Court ruling against Obamacare, which many of them are publicly rooting for. The new GOP majorities in the House and Senate are unlikely to support a fix to Obamacare after spending the election cycle attacking the law. Top Republicans met on Thursday to discuss their response, but they don't yet have a contingency plan in place.

    "We're obviously doing contingency planning for King v. Burwell," House Ways & Means Chair Paul Ryan (R-WI) told reporters after the meeting. "It would be wrong not to. ... That's something that is an ongoing conversation and we're doing all of our diligence on that."

    It'll be rough sailing for Democrats, too. A Supreme Court ruling that guts a centerpiece of President Barack Obama's signature domestic achievement would be a severe blow. The subsidies are a key pillar of Obamacare; without them the individual mandate requiring most Americans to buy insurance is not viable for the many who would not be able to afford it. Insurance companies would face a loss of customers and are already demanding a fix if the Supreme Court invalidates the federal exchange subsidies. For the Obama administration, the implementation fallout threatens to be chaotic.

    For the Democratic nominee in 2016, the strategy is clearer: accuse the Supreme Court of making an activist decision to gut Obamacare and propose a tweak to the legislative language to make clear the subsidies are permitted on the federal exchange.

    The battle could ultimately turn on whether Republicans devise a viable health care solution of their own and persuade voters it would be better than Obamacare. The optics of a Supreme Court rebuke of Obamacare may be helpful to them. But the task of crafting an alternative to Obamacare has eluded Republicans in Congress, who have failed to coalesce around any plan of their own in the five years since the law was enacted.

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    doctor nurse hospital

    For many Americans, the "fun" part about filing their taxes is dealing with the way the tax laws change from year to year.

    For 2014, the Affordable Care Act will provide more tax-filing fun than ever before.

    Actually, most Americans will not have to make any dramatic changes to their tax forms because of the ACA.

    If a taxpayer was covered for insurance the entirety of 2014, all they need do is mark on their return that they were covered by an employee-based policy, Medicaid, Medicare, or a personally owned policy.

    If that covers your situation, you can relax.

    However, if for any part of 2014 you were without health insurance, you need to get your hands on Form 8965, which will determine if you can claim an exemption from the requirement to have insurance (based on religious, ethnic or income level allowances) or to calculate the penalty for the months you did not have coverage.

    One of the main elements of the ACA is that everybody who can afford to have insurance must have insurance.

    The penalty for not having health insurance in 2014 is a maximum of $95 per adult and half that, $47.50, for children, or 1% of your taxable income above the taxable filing threshold of $10,150, whichever is greater. If you have income greater than $10,000, and you did not have health insurance in 2014, you will pay 1% of your taxable income.

    The amount will increase for 2015, to a maximum of $325 per adult, $162.50 for children, or 2% of taxable income. In 2016, the penalty is $695 per adult and $347.50 per child, or 2.5% of a family's income, whichever is greater.

    You avoid the penalty by having health insurance. You can also avoid the penalty by claiming an exemption, and many of those can be claimed directly on the tax return. One such exemption is if your income is below the filing threshold of $10,150 for an individual.

    Another exemption from the penalty is if you had a short coverage gap of less than three consecutive months.

    Some exemptions are granted through the healthcare marketplace, and could take up to two weeks to process the application. That includes an exemption if health care would cost you more than 8% of your income. In that case, you must get an exemption certificate from the healthcare exchange.

    One very important exemption relates to people living in states that chose not to expand their health care programs. If you experienced a particular hardship, and would have been eligible for Medicaid under the new health care law but could not get Medicaid because of your state's health care law decisions, you are exempt from the tax penalty.

    Other exemption include incarcerated citizens, Native Americans who are covered by the Indian Health Service, or people who object to health care for religious reasons.

    SEE ALSO: Here Are The Tax Changes You Should Know About This Year

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    In one section the brief quotes the conservative justices acknowledging that the Democratic-led Congress "thought that some States might decline ... to participate in the operation of an exchange." The aim is to rebut the challengers' contention that Congress expected every state to set up an exchange and was blindsided when some three dozen declined to do so.

    "First, it was well understood when the Act was passed that some States would not establish Exchanges for themselves. The very fact that the Act provides for federally-facilitated Exchanges demonstrates that “Congress thought that some States might decline * * * to participate in the operation of an exchange.” NFIB v. Sebelius, 132 S. Ct. 2566, 2665 (2012) (Scalia, Kennedy, Thomas, & Alito, JJ., dissenting).

    obamacareIn a second section of the brief, DOJ quotes the conservatives in NFIB v. Sebelius saying Congress created a "backup scheme" by setting up a federal exchange.

    "The linchpin of petitioners’ account is their assertion (Br. 5, 40-41, 43) that Congress assumed every State would establish an Exchange for itself. But the very fact that the Act includes a “backup scheme” in the form of federally-facilitated Exchanges demonstrates that “Congress thought that some States might decline * * * to participate in the operation of an exchange.” NFIB, 132 S. Ct. at 2665 (Scalia, Kennedy, Thomas, & Alito, JJ., dissenting).

    In a third section of the brief, DOJ quotes a chunk of the 2012 dissent which suggests that restrictions on the subsidies would reduce the incentives of insurers to sell plans, and individuals to buy plans. As a result, "the exchanges would not operate as Congress intended and may not operate at all."

    "Critically, moreover, the Exchanges that Congress directed HHS to set up for States that declined or were unable to do so for themselves would be a futile gesture absent tax credits. “Without the federal subsidies, individuals would lose the main incentive to purchase insurance inside the exchanges,” and insurers would likely “be unwilling to offer insurance inside of exchanges” if they were no longer the exclusive means of reaching subsidized customers. NFIB, 132 S. Ct. at 2674 (Scalia, Kennedy, Thomas, & Alito, JJ., dissenting). “With fewer buyers and even fewer sellers, the exchanges would not operate as Congress intended and may not operate at all.” Ibid.

    The government's brief argues that if the challengers are right that Congress purposefully withheld subsidies as a threat to encourage states to set up exchanges, it would make little sense to create a federal exchange that would be "doomed to fail."

    Yale law professor Abbe Gluck, who flagged the 2012 dissent in August, said it's important because it validates a core argument of the Obamacare administration.

    "The reason the quotes are powerful is that it shows that in 2012, everybody in the nation focusing on the Affordable Care Act read the statute the way the government does," she said. "The goal is not to say 'gotcha.' It's to say 'look, they're saying the statute is crystal clear.' ... The NFIB dissenters understood the statute very well. And they understood the statute to allow [those subsidies]."

    Jonathan Adler, an architect of the legal challenge in King, doubted that the administration's citation of the 2012 dissent would impact the case.

    "It's more of a cute debater's point than a substantive legal point," he said in an email. "It tells you something about the strength of their case."

    Adler pointed to his observation that Scalia tends to takes a "textualist" approach to interpreting laws — one that gives minimal weight to legislative history. For instance, he wrote in UARG v. EPA: "We reaffirm the core administrative-law principle that an agency may not rewrite clear statutory terms to suit its own sense of how the statute should operate."

    Legal experts widely expect Republican-appointed Justices Scalia, Samuel Alito and Clarence Thomas to rule against the government, and the four Democratic-appointed justices to validate the IRS rule allowing subsidies on the federal exchange. The question-marks are Chief Justice John Roberts and Justice Anthony Kennedy, whom Supreme Court scholars say have less clear-cut views of statutory construction.

    Gluck said that as a litigation strategy, the Obama administration's move is "not that unusual." When trying to appeal to a particular justice, she said, lawyers "often cite cases and language that that particular justices wrote."

    Oral arguments are set for March 4, and a decision is expected by the end of June.

    Obama Administration SCOTUS Brief in King v Burwell

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    Part-time Staples workers are furious that they could be fired for working more than 25 hours a week. 

    The company implemented the policy to avoid paying benefits under the Affordable Care Act, reports Sapna Maheshwari at Buzzfeed. The healthcare law mandates that workers with more than 30 hours a week receive healthcare.

    If Staples doesn't offer benefits, it could be fined $3,000 in penalties per person.

    Buzzfeed spoke with several Staples workers who revealed their hours have been drastically cut over the past year. Many reported working as few as 20 hours. 

    The workers started a petition on asking the company not to "cut part-time hours because of Obamacare." 

    "This new policy includes termination of GENERAL MANAGERS if employees ever go over 25 hours a week!"the petition reads."This has lead to some bizarre stories of General Managers telling part-time employees to 'leave now or be fired' in the middle of transactions with customers." 

    The petition has 200,000 signatures. 

    Staples is cutting costs and closing stores as sales continue to slump.

    The company just acquired Office Depot for $6.3 billion. Combined, the two retailers have 58,000 employees. 

    But it's likely that Staples will downsize its workforce as the companies merge. 

    In a statement to Business Insider, Staples denied the policy is a response to the Affordable Care Act.

    "Staples’ policy regarding part-time associates weekly hours pre-dates the Affordable Care Act by many years. Some managers may have reiterated the existing policy to our associates as part of our ongoing efforts to improve the efficiency and competitiveness of our stores. In fact, this policy has been in place for more than a decade."

    Do you work at Staples and want to share your story? Email

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    burr hatchThe following post is analysis by The Center For Public Integrity columnist Wendell Potter.

    We got a glimpse last week of what would happen to our health care system if Republicans increase their control of Congress and win the White House in 2016.

    Gone would be the part of Obamacare that Americans tell pollsters they don’t like: the requirement that they enroll in some kind of health plan or pay a penalty that grows more severe every year.

    In addition, the GOP would get rid of the provision mandating that employers with more than 50 workers offer subsidized coverage.

    But the GOP would also eliminate the existing parts of the law protecting us from insurance company practices that used to keep millions of us in the ranks of the uninsured and underinsured—and just an illness or accident away from financial ruin.  

    Of course the sponsors of the Republican alternative —called the Patient Choice, Affordability, Responsibility and Empowerment Act—or Patient CARE—don’t spin it that way.  In fact, the language they use makes their plan sound like a simple, common sense, no-brainer alternative to the Affordable Care Act (a.k.a., Obamacare.)

    "We can lower costs and expand access to quality coverage and care by empowering individuals and their families to make their own health care decisions, rather than having the federal government make those decisions for them," said Sen. Richard M. Burr (R-North Carolina), one of the three authors of the plan. The others are Sen. Orrin Hatch, (R-Utah), who now chairs the Senate Finance Committee, and Fred Upton (R-Michigan.), the chairman of the House Energy and Commerce Committee Chairman.

    As always, though, the devil is in the details. The reality is that the GOP plan would take us back to the days when insurers could sell junk policies, charge older folks more than they can today and calculate premiums based on a person’s health status. This means that a breast cancer survivor or a diabetic or someone recovering from a heart attack—or even a young person born with a disability or congenital disease—would have to pay a fortune for decent coverage if, God forbid, they let their existing policy lapse for two months or longer.

    160764479The Republican sponsors say their plan would restore freedom of choice they claim was taken away by Obamacare.  There is some truth to that. The Affordable Care Act requires health insurance policies to cover 10 essential benefits, ranging from preventive care to prescription drugs and a stay in the hospital. People no longer have the freedom to buy policies so skimpy they have to pay almost all of their medical bills out of their own pockets. The Patient CARE Act would restore that freedom.  And it would also restore to insurance companies the freedom to set annual limits on coverage.

    The health insurance exchanges would disappear in most if not all states because the federal funding to help run them would evaporate under the GOP plan. One of the benefits of the exchanges is the ability it gives us to shop online for coverage and compare features and costs of one plan versus another. Health insurance agents and brokers would probably love to see those features disappear,  but their gain would be our loss.

    To increase competition, the GOP lawmakers say they would allow insurers to sell coverage across state lines. They made no mention of the fact that health insurance is regulated largely at the state level and that federal law doesn’t bar insurers from crossing state lines today. 

    The Medicaid expansion under Obamacare would also go away, as would the federal subsidies available to help low-income families and individuals pay their premiums and cover some of their out-of-pocket expenses. Under the GOP plan, the states would receive block grants from the federal government to help finance their Medicaid programs, meaning the feds would have far less say as to how the states provide coverage to the poor.

    The GOP plan would also provide aid only to people making up to three times the federal poverty level—and in the form of refundable tax credits—as opposed to four times the poverty level via federal subsidies under Obamacare.  

    As a result, many—probably millions—of low- to moderate-income people who were able to buy coverage as a result of Obamacare would once again find the cost of health insurance prohibitively expensive.

    Many folks in their 40s, 50s and early 60s would also be dumped back into the ranks of the uninsured or underinsured. Against the wishes of insurance industry lobbyists, Congress restricted insurers’ ability to charge older folks more than three times as much as younger people for the exact same coverage when it passed Obamacare. The industry wanted to be able to charge them at least five times as much. The GOP plan would grant that wish.

    It’s important to note that the Patient CARE Act is not really a piece of legislation.  If it were a bill instead of just a “vision,” as Burr, Hatch and Upton refer to their ideas, the Congressional Budget Office would have to assess the effect it would have on the budget and our health care system. That would not be pretty. So don’t expect the Patient CARE Act to become a bill anytime soon.  

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    In the final day leading up to Obamacare’s sign-up deadline, the website was once again hit with technical glitches that prevented people from signing up for health insurance.

    The problems stemmed from a function on the site that verifies people’s income to determine if they qualify for federal subsidies, and if so, how much.

    Officials from the Department of Health and Human Services confirmed the issues on Saturday, saying some people weren’t able to submit their applications because the website couldn’t verify their income.

    On Saturday afternoon, health officials instructed people to continue creating accounts on, browse their options for coverage, and then save their progress so they could return later when the issues had been resolved.

    The glitches were fixed around 8 p.m., according to HHS officials, who said they would be contacting consumers who had issues to tell them they can continue completing their applications. It’s unclear if the deadline to sign up will be extended. is the main website for consumers living in the 37 states that rely on the federal exchange. The website had been relatively glitch free this year, compared to Obamacare’s rollout last year, when the site was so plagued with problems that only six people were able to sign up for coverage on the first day. To date, the administration has spent a total $2.2 billion to build and repair the website.

    obamacare websiteEven though the site is complicated, the user base is relatively small.  By comparison, Facebook has 1.9 billion users and experts say Facebook could have been built easily for $1 million in 9 months – not the nearly 3 years it took to launch the first version of

    HHS officials didn’t go into detail about what caused the verification problem. But some are concerned that it could lead to more issues down the road.

    The administration ran into verification problems last summer, when it couldn’t verify legal citizenship status for more than 300,000 applicants. Under the law, Obamacare enrollees must be able to prove they are legally residing in the United States.

    However, if they can’t confirm their status, they aren’t eligible for coverage or subsidies on the exchanges. In September, more than 100,000 people were kicked off their plans legal status issues. Last week, another 200,000 were told they would be dropped from coverage for failing to verify that they are legally living in the United States. The issues with verification could cause similar problems down the road.

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    Five Republican governors, including 2016 presidential hopeful, Scott Walker of Wisconsin, have vowed not to step in and restore federal health care subsidies to millions of people in their states if the Supreme Court strikes down a key piece of Obamacare, Reuters first reported.

    In March, the Court will begin hearing oral arguments in the high-stakes case of King v. Burwell that challenges whether language in the health law provides federal subsidies for people signing up for coverage through the federal exchange.

    The plaintiffs charge that the wording of the law only mentions state exchanges, and does not provide for subsidizing anyone on the federal exchange. If the Court agrees, more than 6 million people on the federal exchange would lose their subsidized coverage.

    This could have a disastrous impact on the entire health care industry. Last week, the Urban Institute estimated that such a ruling would leave more than 8 million people without health coverage, driving up premiums and hospital costs.

    But there are options to soften the blow if the Court rules against the administration—especially at the state level. States using the federal exchange could restore subsidies for their residents if they set up their own exchanges.

    Of course, politics makes that option a lot more challenging—especially in heavily Republican states that staunchly oppose the president’s health care law including the five Republican governors who have already taken this option off the table.

    According to Reuters, governors of Louisiana, Mississippi, Nebraska, South Carolina and Wisconsin all said they would stick by their original decision not to create their own exchanges—largely because of their overall opposition to the health care law.

    Other states including Georgia, Missouri, Montana and Tennessee with Republican-controlled state legislators are also not likely to set up their own exchanges under Obamacare. Reuters noted that all nine states combined have 1.4 million Obamacare enrollees receiving federal subsidies at risk of being lost if the Court strikes them down.

    The major implications of the Court’s ruling could prompt these states to change their minds, however, as millions of low to middle income people would be hit with sky-high health care costs.

    Other states like Delaware, Maine, Ohio and Pennsylvania, meanwhile are in the process of figuring out a way to deal with an adverse Court ruling—in order to keep subsidies flowing to their residents.

    Legal experts say that states don’t necessarily need to create a traditional state exchange with a website. Instead, they could use workarounds that allow them to establish a legal state exchange (basically on paper) while still using the federal website.

    States have until June to decide if they want to set up their own exchanges—or six months before the open enrollment period begins in November. This could be a tight deadline, as the Court’s decision will come around the same time.

    Another option, though far less likely, is for Congress to amend the law with language about the federal exchange. Of course, anyone vaguely familiar with the goings on over on Capitol Hill knows that any Obamacare fix—especially this one—isn’t likely to happen with a Republican-controlled Congress. House Budget Committee Chairman Paul Ryan said as much during an interview on Bloomberg television. Instead the GOP is likely to use an adverse SCOTUS ruling as an opening to repeal and replace Obamacare.

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    The reason is pretty simple, as the Kaiser Family Foundation's Larry Levitt explained to TPM: The employer mandate's penalties, the teeth that make the policy work, are triggered by the tax credits that would be wiped out in the new lawsuit against Obamacare. Employers with enough employees (100 in 2015; 50 starting in 2016) are required to provide insurance. If they don't, and their employees go to the law's insurance exchanges, qualify for a tax credit, and buy insurance, then the employer is assessed a penalty.

    "Penalties on employers that don’t offer coverage to their workers are only triggered if one or more of their workers receive subsidies in a marketplace," Levitt said. "If there are no subsidies, there are no employer penalties."

    But that makes the stance of top business groups toward the King v. Burwell lawsuit a little befuddling. They have made repealing the employer mandate a top priority since Obamacare passed. A ruling against the law would effectively repeal it by three-fourths. It's easy to imagine any "grand bargain" to restore the subsidies on would involve its full repeal -- and even the law's supporters have conceded that the mandate is expendable.

    obamacare websiteThe elimination of the mandate in three-quarters of the states through the lawsuit would go a long way toward achieving the goals of big business groups like the Chamber of Commerce and the National Federation of Independent Businesses, but those groups have not weighed in to support it. Neither the Chamber of Commerce nor the NFIB would comment to TPM on the King case's implications for the mandate.

    "The outcome will be important to all users of the healthcare system if the plaintiffs win their argument. There will be direct and indirect effects associated with that decision," Amanda Austin, a health policy expert at NFIB, told TPM.

    "For now, our position still stands that NFIB members dislike the employer mandate and want to see it gone," she continued. "However, at this stage, NFIB is not commenting on whether this is the vehicle for it to ride on."

    The exact effects of the potential ruling for the mandate haven't been mapped out, but experts have studied the expected effects of full repeal of the employer mandate. About three-fourths of the marketplace and uninsured populations live in states. If you scale that to the previous estimates of the effects of full repeal of the employer mandate, it would mean up to 375,000 people would lose employer coverage.

    Beyond that, according to Levitt, such a ruling would have unpredictable and potentially deleterious effects for those who still have their employer-sponsored insurance. The employer mandate not only compelled employers to offer health coverage, but to provide adequate health coverage. If their plan wasn't sufficient and an employee went to and used a tax credit to purchase a better plan, that would also subject the employer to a penalty.

    But again, Obamacare would lose that stick if the Court rules to invalidate tax credits on the federal exchange. Without the employer mandate, the law doesn't require employers to provide coverage that meet certain standards for benefits or for cost-sharing. Employers could offer much less generous coverage, Levitt said, while their employees would still satisfy the other mandate: the individual mandate.

    "If the court sides with the plaintiffs and the employer requirement goes away in many states, there would be nothing to stop employers from offering very skinny plans that would also satisfy the individual mandate for workers," he said.

    Correction: This piece originally misstated the effect on employer coverage using the Urban Institute's estimates. An estimated 375,000 people would lose insurance, not 150,000 as initially reported.

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    The law's defenders in King v. Burwell are preoccupied with courting the chief justice, whom they view as their most "winnable" swing vote, according to sources close to the case.

    In 2012 he broke with conservatives and saved the Affordable Care Act from the politically-charged legal attack that nearly killed it.

    "As a matter of legal doctrine it's not a difficult case. What's making it difficult is the politics of the ACA. And the chief justice has already shown that he's able to rise above politics," said Yale law professor Abbe Gluck, who filed a brief in support of the ACA subsidies at stake.

    The law's defenders want the Court to believe that its legitimacy would suffer if it guts a sitting president's signature initiative in a case they claim is a partisan hit job. They also want to stress that the real world consequences would be devastating for millions, and that Congress has no viable plan to prevent the chaos in the health care system.

    "The chief cares very much about preserving the credibility of the court and assuring that it doesn't act as a political institution," said University of Michigan law professor Nick Bagley, who supports the government's view. "This case is widely perceived as an ideological bid by opponents of the ACA to revisit a political decision that's already been made."

    Legally, part of the Obama administration's strategy is to shatter the narrative that the law's authors intended to withhold the subsidies to entice states to build exchanges. The government will argue that the statute, read as a whole, supports broad subsidy eligibility and that legal precedent requires deference to agencies implementing the law if the text is ambiguous.

    One way for the Obama administration to appeal to Roberts is to offer him a way to uphold the subsidies while advancing long-term conservative legal goals, as he did in 2012 by making the Medicaid expansion optional.

    Here's Where People Could Lose Their Health Insurance SubsidiesThat's what its lawyers are effectively doing when they contend that it would violate states' rights to deny subsidies without a clear warning that they were contingent on setting up state exchanges. The federalism argument is a late addition to the strategy — the government didn't make it at the trial court level.

    "It has been the conservative project for years to get federalism entrenched as part of the everyday bucket when deciding cases," Gluck said. "It's certainly possible that those doctrines [being advocated here in favor of the Obamacare subsidies] can be used to further principles that are associated with conservative values."

    The administration's other challenge with Roberts, apart from the poor wording in the statute, is that unlike in 2012 the upcoming case doesn't require him to reinterpret the Constitution. Instead Roberts could argue, as he did when he slashed the Voting Rights Act, that Congress is free to fix the law.

    Obamacare legal defenders are less optimistic about winning over Justice Anthony Kennedy, despite his reputation as the typical swing vote, given his demonstrated antipathy toward the ACA in 2012 and the 2014 Hobby Lobby case over the birth control mandate. The four Democratic-appointed justices are seen as a safe bet to uphold the subsidies, while Republican-appointed Justices Antonin Scalia, Clarence Thomas and Samuel Alito are all but written off.

    Conservative legal experts are also worried about losing Chief Justice Roberts, though they only say so privately. Publicly they are confident in victory, but Roberts' protectiveness of the court's institutional standing makes them fret that he'll be reluctant to dismantle Obamacare. Michael Carvin, the lawyer who will argue before the justices for Kingtold TPM in September (before the Supreme Court took the case) that he didn't expect to lose any of the five Republican-appointed justices.

    Neera Tanden, the president of the Center for American Progress and a member of Obama's health care team during the drafting of the law, told TPM that the Court would face public blowback if it invalidates the subsidies and puts insurance out of reach for millions. She said the real world consequences "will and should play a large role, if not the largest role, in the decision."

    "It'll be nine justices making a decision that adversely affects 9 million people. So of course, if the court chooses to go down a road that creates chaos for millions of people, they will be held accountable," Tanden said. "We would really be returning to a pre-New Deal period, looking back 100 years where the Court's judicial activism unraveled legislation by elected members of Congress."

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    obamacare health insurance

    The Obamacare website had another major stumble on Friday when the White House revealed it sent hundreds of thousands of customers bad tax information.

    According to the Associated Press, the Obama administration said about 800,000 HealthCare.Gov customers were sent the wrong tax information. Those customers will now have to delay filing their 2014 tax forms. 

    "California, which is running its own insurance market, just announced a similar problem affecting about 100,000 people in that state," the AP reported. "The errors mean that nearly 1 million people may have to wait longer to get their tax refunds this year. Another 50,000 or so who already filed may have to resubmit their returns.", the online insurance exchange set up by the Affordable Care Act (also known as Obamacare), had an infamously rocky rollout when it launched in 2013. At the time, hundreds of thousands of consumers couldn't access the website and the White House struggled to fix its bugs.

    Politico reported this week that is "still a mess."

    "The 'back end' of the Obamacare website still isn’t properly wired to the health insurance companies," Rachana Pradhan and Brett Norman wrote. "Subsidy payments aren’t automated, so the insurers get payments based on estimates. And adding information like a marriage or the birth of a child is a convoluted, multi-step process."

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    larry ellison

    As if Oregon's politics couldn't get any crazier, what with with the strange resignation of its governor this month, add this to the mix: its attorney general has launched a second ugly lawsuit against huge Silicon Valley tech company, Oracle.

    This one is also related to the infamously botched Obamacare health exchange Oracle was supposed to provide for the state. Oracle and Oregon are suing each other for millions about that failed site.

    Now Oracle is refusing to host the one part of the system that both parties agreed worked fine: enrollment for Medicaid, which provides health coverage for the poor. Oregon's new lawsuit claims Oracle backed out of a promise to renew its contract.

    When Oregon's contract with Oracle for Medicaid enrollment expires at the end of February, Oracle says it will not renew it. The system will go offline unless the state can figure out how to quickly move it (not likely) or get a judge to force Oracle to keep hosting it. This system is used to process new Medicaid applications and renew existing ones. All told, the system processes 26,000 low-income people each week, according to the state’s suit.

    Oracle, naturally, says it made no such promise, and it blames the state for failing to "anticipate and plan" for the end of the contract — especially since the two parties were already in litigation.

    As part of that litigation, Oregon is contemplating forever banning Oracle from all future contracts with the state.

    Here's how the dispute began. Oracle was supposed to build a state system that lets people buy health insurance that would be the envy of all the other states.

    Instead, the state spent about $200 million on the system, and paid Oracle more than $130 million before pulling the plug and filing a lawsuit over supposed problems with the site, the Oregonian reports.

    Oracle — which says the state still owes it about $25 million — filed a counter suit saying the site worked fine, and that Oregon pulled the plug for political reasons. However, after missing deadline after deadline, the site was limping along, requiring people to use paper forms for at least part of the application process. Oracle says it had urged the state to hire a professional IT project manager, a systems integrator, but the state chose to manage the project on its own. Oracle blamed poor project management for most of the website's problems.

    In a letter responding to the second lawsuit, Oracle attorney Dorian Daley points out the irony in suing Oracle while also trying to force it to continue working for the state.

    "After accusing Oracle of fraud and racketeering, and asking the court to protect the public from this alleged malfeasance by preventing Oracle from doing business with the State in the future, you are insisting that Oracle sign a new contract to continue working for the State for another year," she writes.

    Indeed, Oracle has point: The state was trying to ban Oracle while making no plans to hire an alternative.

    This healthcare exchange was supposed to be a point of pride for the state and the company. Business Insider has talked to Oracle employees who tell us they feel ashamed of the whole debacle and their company's role in it, whoever is ultimately to blame.

    Here's the full scathing letter Oracle sent to the state and also sent to us when we asked Oracle for comment.


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    Single people have a lot of sex.

    It doesn't really matter who she is or how much money she makes. The likelihood that a single woman has had sex in the last year is roughly the same across income groups — about 70%.

    What Happens Before And After Sex Varies Widely

    However, what happens during and after having sex is very different depending on how much money a woman makes, though.

    Birth rates, vary widely based on income. Single women between 15 and 44 from the lowest income bracket (>100% of the federal poverty line, $11,770) in the US are five times more likely to have a child than women in the highest 20% of incomes (>400% of the poverty line).

    A new Brookings paper takes a look at why that is.

    The paper, by Richard Reeves and Joanna Venator, finds that both contraceptive use and abortion rates factor into the difference in the birth rate. Higher income women are more likely to use contraception, the contraception they use is more likely to be effective, and they are more likely to get an abortion than lower income women. 

    The Findings

    In the study, Reeves and Venator controlled for both of these factors — contraceptive use and abortion — and looked at how it would affect the birth rate. They asked, if every income group used contraception and got abortions at the same rate as the highest income women, what would happen? Here are the results: 


    Pretty much across the board (with the exception of the fourth group, which is incomes 300-400% of the official poverty level and behaves strangely*), abortions at the rate of wealthy women cause the birth rate to go down by about a third. Using contraception at the rate of the wealthiest women causes the birth rate to go down by nearly half.

    Here's The Thing, Though

    There's a major caveat here, which is this isn't a moral argument. A high birth rate for low income women is only bad if those women would rather not have had those children.

    There's a body of sociological research, most prominently being done by Kathryn Edin, that argues this isn't true. Edin's 2005 book with Maria Kefalas, "Promises I Can Keep," finds that "child rearing was so central to young women’s outlook on life that they were unwilling to postpone having children until they could find a suitable husband—which could take years, if ever." 

    However, it's interesting to note that the Brookings paper actually surveyed the women in the study about how they would feel about getting pregnant and the results were largely equal across income groups: 

    Screen Shot 2015 02 27 at 5.05.32 PM

    Because of this, the paper's authors think that income is the real factor that matters here. "Our view is that income gaps in accessibility and knowledge are the key factors here," they write. This is an economic issue, and a policy issue.

    The most effective forms of contraception — long-acting reversible types like IUDs — have high up-front costs, even if they are cheaper than other forms of birth control over the long run. Abortions are expensive, and depending on where you live, just plain unavailable without traveling a long distance. The ACA contraceptive mandate is to some extent helping with the former issue, but the government is more likely to restrict abortions than make them more available and affordable.

    The fact is that controlling fertility remains expensive for women in this country.

    * The group between 300-400% of the federal poverty level (that's an income of roughly $35,000-47,000 per year) behaves differently than other groups. I don't have any idea why, but I wonder if there's a stronger religious component here? Or if women at this level of income feel stable, but aren't doing the career-ladder climbing that women at the top level are, so are more likely to decide to go ahead with an unintended pregnancy? Anyway, there's no evidence for either of those theories, so moving on... 

    SEE ALSO: Bill Gross wonders which breed of dog he would be

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    A man looks over the Affordable Care Act (commonly known as Obamacare) signup page on the website in New York in this October 2, 2013 photo illustration.  REUTERS/Mike Segar

    WASHINGTON (Reuters) - The U.S. Supreme Court will weigh a second major case targeting President Barack Obama's healthcare law on Wednesday when it considers a conservative challenge to tax subsidies critical to the measure's implementation.

    The case is set for a one-hour oral argument starting just after 10 a.m., with a ruling due by the end of June.

    If a majority of the nine justices rules against the administration, up to 7.5 million people in at least 34 states would lose subsidies that help low- and moderate-income people afford private health insurance, unless Congress or the affected states act immediately.

    Such a ruling could also have a broader impact by deterring younger, healthier people from buying health insurance, which would lead to premiums rising for older, less healthy people who need healthcare most, said Rand Corporation economist Christine Eibner.

    "It would cause major disruption to the individual insurance market," Eibner added.

    The Democratic-backed law, narrowly passed by Congress over unified Republican opposition, aimed to help millions of Americans who lacked any health insurance afford coverage.

    The case does not affect people who obtain health insurance through their employer.

    The legal question is whether only people who have bought insurance on state exchanges qualify for the tax-credit subsidies.

    Thirteen states and the District of Columbia have set up such exchanges, with another 34 run by the federal government and three operating as state-federal hybrids.

    In a Reuters interview on Monday, Obama said there is "not a plausible legal basis" for the court to rule against the law, calling the matter a "pretty straightforward case of statutory interpretation."

    obamacare protest supreme courtThe first time the 2010 Affordable Care Act, dubbed Obamacare, came before the justices three years ago, the court was split 5-4. Chief Justice John Roberts, a conservative appointed by President George W. Bush, was the key swing vote, siding with the court's four liberals to uphold the law on constitutional grounds.

    Roberts and fellow conservative Justice Anthony Kennedy are the most likely swing votes in the new case.

    The court will be focusing on whether a four-word phrase in the law has been correctly interpreted by the administration to allow subsidies to be available nationwide.

    That provision says subsidies are available to those buying insurance on exchanges "established by the state." The challengers, financed by a libertarian Washington group called the Competitive Enterprise Institute, say the government should lose based on the plain meaning of that phrase.

    The government, backed by the healthcare industry, says other provisions make clear Congress intended the subsidies to be available nationwide regardless of whether states set up their own exchanges or leave the task to the federal government.

    The case is King v. Burwell, U.S. Supreme Court, No. 14-114.

    (Editing by Will Dunham)

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    man hospital bed emergency room

    The Supreme Court will hear arguments Wednesday in a new Obamacare fight over whether the federal government can keep subsidizing insurance in the roughly three dozen states that refused to set up healthcare marketplaces

    The justices' decision could gut Obama's health reform law and determine whether thousands of Americans live or die, according to a brief filed by public health professionals in that case.

    The dispute revolves around the interpretation of four words in the law. Obamacare opponents argue the law limits health insurance subsidies to people living where a healthcare exchange had been "established by a state" because that is what the Affordable Care Act (ACA) technically says. If the Supreme Court agrees with that literal reading of those four words, 8.2 million people in America will lose their health insurance, according to the amicus brief filed by the American Public Health Association.

    That brief went on to say that the "interrelationship between insurance coverage, healthcare access, and population health" means that a loss of insurance of that magnitude translates to 9,800 additional deaths every single year.

    "Nothing in the ACA requires these terrible health outcomes," the brief stated.

    This is the second time the high court has heard a challenge to Obamacare. In 2012 the Supreme Court upheld another key part of Obamacare — the requirement that most people buy health insurance or pay a penalty. To make insurance affordable, the law stipulated that states would set up subsidized exchanges. If the states could not set up exchanges, the law said the federal government would create one for the state.

    In fact, the majority of states failed to establish their own exchanges, forcing the federal government to step in. Now, opponents of the law — four Virginia residents who don't want to buy health insurance — claim the law doesn't authorize subsidies for people buying insurance from exchanges set up by the federal government.

    They point to text of the law specifying that subsidized insurance is available through "exchanges established by the state." Read literally, that would exclude exchanges the federal government established on behalf of states.

    But the federal government says those four words must be read in the context of the law. In a brief to the Supreme Court, the US Secretary of Health and Human Services points out that subsidized insurance is the key to making the entire law work. Those four words shouldn't be read in a vacuum, the brief said.

    While the Supreme Court hears the case Wednesday, it could be months before a decision is reached. Chief Justice John Roberts, a conservative, was the surprise swing vote the last time the court ruled on Obamacare and could play a decisive role in the case again.

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    Cathey Park of Cambridge, Massachusetts wears a cast for her broken wrist with "I Love Obamacare" written upon it prior to U.S. President Barack Obama's arrival to speak about health insurance at Faneuil Hall in Boston October 30, 2013 in this file picture. REUTERS/Kevin Lamarque  NEW YORK (Reuters) - As the U.S. Supreme Court takes on a make-or-break Obamacare case this week, a growing number of U.S. patients and their doctors are already devising a Plan B in case they lose medical coverage.

    The Court's ruling, expected by late June, will determine whether millions of Americans will keep receiving federal subsidies to help them pay for private health insurance under President Barack Obama's healthcare law.

    The White House, which said it is confident the justices will rule in favor of the subsidies that are a key element of Obamacare, said it has no immediate fix if the decision goes the other way.

    But even physicians who think the court will uphold the subsidies are gearing up for the worst.

    Worried about newly-insured patients such as those who have just begun treatment for cancer or other serious illnesses, they are dusting off playbooks they retired when Obamacare slashed the number of uninsured people.

    Interviews with doctors reached through professional groups show that they are lining up free clinics to care for patients with chronic illnesses, asking pharmaceutical companies to provide discounted drugs, and moving up preventive-care appointments and complicated procedures.

    "We have to be able to navigate this on behalf of our patients if it comes about," said Dr. Jeff Huebner, a family physician in Madison, Wisconsin, one of the affected states.

    In King v. Burwell, the Court will decide whether the Affordable Care Act permits government subsidies for citizens of at least 34 states which use the federal marketplace to buy health insurance. It will hear oral arguments on Wednesday.

    If the justices rule that only residents of states running their own exchanges are eligible for subsidies, some 9.3 million people will have to pay their full monthly premium or lose coverage, estimates the nonpartisan Urban Institute. About 6 million are expected to be unable to afford it.

    Many providers as well as patients are unaware of the looming threat, but some physicians are already preparing for it.

    Last weekend, leaders of the National Physicians Alliance, which supports the Affordable Care Act and works to improve access to medical care, met in Washington to discuss how to work with community organizations to arrange healthcare for people who might become uninsured, said Huebner, who chairs the group's policy committee.

    "The ideas include finding organizations that make referrals to free clinics, encouraging patients to check if they qualify for Medicaid or other state programs, and if they can't get insurance then find a regular source of care that accepts payment on a sliding scale" based on ability to pay, Huebner said.

    He and other physicians are also scheduling Obamacare patients for preventive screenings, completing lab work, and writing prescription refills.

    "I would advise patients in this boat to schedule a visit with their primary care provider as soon as they can" to set up "transition plans," Huebner said.



    If the court rules against the administration, premium subsidies for people in the affected states could end immediately, though insurers would be obliged to give 90 days notice before ending coverage, according to Aetna Inc. <aet.n> chief executive Mark Bertolini. None of the affected states have announced contingency plans, but some are considering alternatives to help residents maintain coverage..

    In Brewton, Alabama, pediatrician Marsha Raulerson has persuaded one drug company to provide an expensive asthma medication to one of her patients if she loses her insurance.

    "But after a few months you have to re-apply" and show that the patient is still unable to afford medication, Raulerson said. "It's not an easy process, especially if you have to do it for a lot of patients." She is also stockpiling as many free samples as she can.

    Dr. Robert Wergin, a primary care physician in Milford, Nebraska, is scrambling to locate labs and imaging centers that offer the lowest prices for blood tests, X-rays and MRIs.

    "Around here, people feel responsible for their bills and I'm not sure they would come in if they lost insurance and couldn't pay," Wergin said.

    Some patients, reached through social service organizations that helped them sign up for Obamacare, are aware of the potential loss of subsidies and are trying to schedule medical procedures before the Court rules.

    Yolanda Diaz, 27, is one of them. A single mother of two, she suffers from occasional blackouts that last several minutes. She cannot afford the full premium on her wages as a pantry manager at Brevard County, Florida, community center so she pays $74.95 a month and the rest is covered by a $205 Obamacare subsidy.

    Her coverage began this month, Diaz said, and the first thing she did was make appointments for an MRI and CT scans in hopes of identifying the cause of the blackouts.

    "I would hate to have to go to the ER, but if the subsidies get taken away I don't know what I'll do," she said. U.S. law requires hospitals to treat all emergency cases regardless of ability to pay, so many uninsured patients seek care there.

    Of those expected to be priced out of insurance in case of unfavorable ruling, the Urban Institute estimated 81 percent are, like Diaz, employed full- or part-time.

    So is Theresa Cabot-Walmer. The 58-year-old Pennsylvanian pays $79 a month and receives a subsidy of about $400. On her 5-hours-a-day job as a shipping clerk she could never afford the full premium, she said.

    Her coverage has allowed her to see a physical therapist for a serious knee injury and avoid a knee-replacement surgery.

    If the Court eliminates subsidies, she plans to ask if the therapist will accept lower payments. But because that is not a sure thing, Cabot-Walmer is considering her plan B.

    "I might try to schedule knee-replacement surgery while I still have insurance."

    (Reporting by Sharon Begley and Caroline Humer; Editing by Michele Gershberg and Tomasz Janowski)

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