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The latest news on Obamacare from Business Insider

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  • 05/29/15--05:34: Why doctors quit
  • Doctor surgeon surgery scrubs

    About a decade ago, a doctor friend was lamenting the increasingly frustrating conditions of clinical practice. "How did you know to get out of medicine in 1978?" he asked with a smile.

    "I didn't," I replied. "I had no idea what was coming. I just felt I'd chosen the wrong vocation."

    I was reminded of this exchange upon receiving my med-school class's 40th-reunion report and reading some of the entries.

    In general, my classmates felt fulfilled by family, friends and the considerable achievements of their professional lives. But there was an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.

    The complaint was not financial but vocational — an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to "provider."

    As one of them wrote, "My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn't stand everything else." By which he meant "a never-ending attack on the profession from government, insurance companies, and lawyers . . . progressively intrusive and usually unproductive rules and regulations," topped by an electronic health records (EHR) mandate that produces nothing more than "billing and legal documents"— and degraded medicine.

    I hear this everywhere. Virtually every doctor and doctors' group I speak to cites the same litany, with particular bitterness about the EHR mandate. As another classmate wrote, "The introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time."

    You may have zero sympathy for doctors, but think about the extraordinary loss to society — and maybe to you, one day — of driving away 40 years of irreplaceable clinical experience.

    surgeon, doctor, ORAnd for what? The newly elected Barack Obama told the nation in 2009 that "it just won't save billions of dollars"— $77 billion a year, promised the administration — "and thousands of jobs, it will save lives." He then threw a cool $27 billion at going paperless by 2015.

    It's 2015 and what have we achieved? The $27 billion is gone, of course. The $77 billion in savings became a joke. Indeed, reported the Health and Human Services inspector general in 2014, "EHR technology can make it easier to commit fraud," as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.

    That's just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity.

    This hardly stays the long arm of the health-care police, however. As of Jan. 1, 2015, if you haven't gone electronic, your Medicare payments will be cut, by 1 percent this year, rising to 3 percent (potentially 5 percent) in subsequent years.

    obamacare health insuranceThen there is the toll on doctors' time and patient care. One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.

    Forget the numbers. Think just of your own doctor's visits, of how much less listening, examining, even eye contact goes on, given the need for scrolling, clicking and box checking.

    The geniuses who rammed this through undoubtedly thought they were rationalizing health care. After all, banking went electronic. Why not medicine?

    Bellevue Hospital Works Ebola PrepBecause banks deal with nothing but data. They don't listen to your heart or examine your groin. Clicking boxes on an endless electronic form turns the patient into a data machine and cancels out the subtlety of a doctor's unique feel and judgment.

    Why did all this happen? Because liberals in a hurry refuse to trust the self-interested wisdom of individual practitioners, who were already adopting EHR on their own, but gradually, organically, as the technology became ripe and the costs tolerable. Instead, Washington picked a date out of a hat and decreed: Digital by 2015.

    As with other such arbitrary arrogance, the results are not pretty. EHR is health care's Solyndra. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.

    Like my old classmates who signed up for patient care — which they still love — and now do data entry.

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    The federal government forms for applying for health coverage are seen at a rally held by supporters of the Affordable Care Act, widely referred to as

    Despite the promise of coverage through the US Affordable Care Act (ACA), the number of people applying for noncompliant, short-term health-insurance policies was up more than 100% in 2014, according to new data available from companies that broker these policies.

    This type of health insurance is exactly the kind that the ACA, known commonly as Obamacare, was supposed to upgrade. Short-term plans provide low-cost coverage for major medical events such as hospital stays, with high deductibles and out-of-pocket costs, and are subject to denial if applicants have preexisting conditions. They do not offer the protections of Obamacare for preventive care or maternity coverage, for example.

    The government does not count these gap plans as qualifying health insurance, so people who have them are subject to penalties for being uninsured.

    Signups at eHealth Inc. to the short-term plans it offers through its website were up to 140,000 in 2014 from 60,000 in 2013, an increase of 134%, according to the company.

    At another short-term carrier, Agile Health Insurance, a subsidiary of Health Insurance Innovations Inc., new policies were up 100% last year over the previous year and are up again so far in 2015, according to Scott Lingle, the company's senior vice president of business development.

    Accounting for much of the jump are individuals who somehow missed the open enrollment period for an Obamacare plan. More than 11.7 million consumers signed up for Obamacare coverage through February 22, according to the government.

    People missed out mostly because of poor communication between consumers, the government, and insurance companies, says Nate Purpura, eHealth's director of PR and content. Those who missed the opportunity to sign up and did not have a qualifying event now have to wait until the next open enrollment period to try again, so they need an insurance plan to bridge the gap.

    Both eHealth and Agile are also seeing new signups from retirees who are looking for a low-cost plan to tide them over until Medicare kicks in at 65. At eHealth, the 55-to-64 age group is now 9% of the market.

    "If you shop for a 50-year-old on, it is very expensive," Agile's Lingle says. "There are people who have looked at the prices and it makes more sense to buy short-term."

    The largest constituency is young, healthy people seeking low-cost catastrophic coverage. Those aged 18 to 34 account for 57% of eHealth's buyers. A typical policy could cost about $100 a month, depending on the state of residency and the features of the plan. 

    These customers include 19-year-old college student Kelly Thomas-Cutshaw, who had no insurance through family and her school did not offer group coverage. Thomas-Cutshaw did not qualify for a subsidy under the ACA because she did not have enough income, yet she could not get Medicaid in Oklahoma, where she goes to school, because she made too much and was not a permanent resident there.

    Over the winter, Thomas-Cutshaw became ill, and she now has a medical bill she says will take her four years to pay off. She decided she needed some plan in place in case she fell ill again.

    When her short-term plan runs out in the fall, she is prepared to sign up for an ACA-compliant major medical plan.

    "I can mostly afford to live, so that's nice," Thomas-Cutshaw said, thanks to a summer job she just landed. "It been a ridiculous and frustrating experience. I don't wish this on other people."

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    obamacareVery soon, the Supreme Court could upend U.S. healthcare. A decision in King v. Burwell is expected by the end of June; five sloppy words in a giant sloppy law could turn Obamacare into Obamabust. What then?

    In that event, healthcare will emerge as a defining issue in the 2016 election. Assuming Hillary Clinton is the Democratic candidate, her failure to develop a national insurance program in 1992 and her secretive missteps along the way, will again grab the nation’s spotlight. At the same time, voters will demand that Republicans outline an alternative to the Affordable Care Act. By 2017, for example, Obamacare could be replaced by Rubiocare.

    As unimaginable as it may seem, the Supreme Court could decide that Obamacare’s authors meant what they said – that participants only in those states that set up their own exchanges were entitled to subsidies for health insurance they were required to buy but unable to afford. (The policy trackers at renowned Wall Street research firm Evercore ISI, for instance, says a ruling against the White House is “likelier than not” but also a “very close case.”)

    There are 37 states that did not establish such exchanges; in most of those states the federal government provided the insurance marketplaces instead. There are approximately 6.4 million Americans at risk of losing subsidies they receive on those federal exchanges.

    Chief Justice John Roberts could again cast the deciding vote in this challenge; the last time round he saved Obamacare by calling the individual mandate a tax, and declaring it legal. This time, Roberts might well calculate that this monstrous law needs an overhaul.  

    Republicans have already begun to craft a response to such a decision. Politically, they need to protect the 6.4 million vulnerable to losing their insurance while at the same time destroying the most heinous aspects of Obamacare. Senator Ron Johnson of Wyoming has made a good start. His Preserving Freedom and Choice in Health Care Act essentially keeps the current system of subsidies in place until August 2017, beyond the election and far enough out to allow for a thoughtful rewrite by Congress.

    obamacare21It revokes the individual and the employer mandates as well as the one-size-fits-all policies that require 50 year-old men to have pregnancy coverage. Johnson modestly describes the proposal as “transitional,” creating minimal disruption while a new healthcare bill is written. Some 30 Republican senators, including Majority Leader Mitch McConnell favor of the bill.

    This seems like an excellent beginning, but does not let GOP candidates off the hook. If they are going to eviscerate the president’s program, they will need an appealing alternative. Little by little, the popularity of Obamacare has grown; in April, for the first time, more people viewed the legislation favorably than unfavorably.   

    After all, the rise in healthcare costs has moderated. Some of the slowing has been the result of the recession, to be sure – as much as 77 percent according to some studies. But there have been other cost containment measures that have also borne fruit, such as a move away from “fee-for-service” billing, which rewarded doctors for extra visits and procedures and towards “outcome-related” compensation. For instance, hospitals have been penalized for re-admissions, a sign of poor care; consequently, some 150,000 fewer Medicare patients were readmitted in 2013, according to The Economist.

    Also, billing by medical providers has become somewhat more transparent, allowing consumers to compare costs. While these elements are popular, a majority still opposes the individual mandate, and wants to see the bill revised. If proposed huge increases in premiums start sifting through next year, the bill’s popularity will again take a hit.

    Republicans need a plan, based on common-sense market-driven guidelines. 

    What should those principles be? Here are some ideas:

    1)     All Americans, living in the richest country on earth, should have access to healthcare.  

    2)     Do away with the individual mandate, and the employer mandate.  Require that insurance be portable, and give individuals the same tax breaks as companies. A high-risk federally subsidized catastrophe pool should be available for uninsured individuals who face sudden dire illness. High earners would not be eligible, thus undermining the opportunity for young people who can afford insurance to roll the dice.

    3)     Allow insurers to compete across state lines, something that even Obamacare-loving Democrats back. Competition would drive down prices, making insurance more affordable. Don’t believe it? Tired of the Geico gecko?

    4)     Make sure that the system is set up so that patients have “skin in the game.”  Our medical system is expensive in part because many of us lucky enough to have employer-provided insurance don’t pay much towards our care. As a result, we gladly undergo marginally beneficial tests and procedures – treatments that we might resist if we had to pay for them. Progress is visible in this arena, but we have farther to go.

    5)     Focus on holding down costs. That was supposed to be the chief objective of the Affordable Care Act. Allow the private sector to play a bigger role. Wal-Mart has driven down the cost of nearly everything Americans consume – let’s see what a roll-out of their walk-in clinics can accomplish for healthcare.

    6)     Continue reforming Medicare and Medicaid so as to encourage productivity.

    7)     Get moving on tort reform.

    8)     Require insurers to allow children to stay on their parents’ insurance until age 26. This has been popular; there is no reason to change it.

    9)     Get rid of any requirements that stifle job creation. That was, and remains, exactly the wrong direction for this country.

    obamacareThere are other ideas out there – giving small companies the opportunity to operate as a group, to exact better premium prices, or health savings accounts, that should be explored. Many have been proposed by doctors serving in Congress; they may actually know what they are talking about.

    Here is what Republicans must not do: use an overhaul of Obamacare as an opportunity to push a controversial social agenda. For example, women must have access to birth control, period.

    There is a great opportunity here – not just for the GOP, but for the nation. For all the upset and economic drag perpetrated by Obamacare, we still have 30 million Americans without insurance. Surely Republicans can do better.

    SEE ALSO: Killing Obamacare would be a terrible shame

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    U.S. President Barack Obama

    WASHINGTON (AP) -- President Barack Obama says he has no alternate plan if the Supreme Court invalidates a key benefit of his health care law and he places the burden on the Republican-controlled Congress to fix the law if the high court wipes out insurance for millions of Americans.

    Voicing confidence he will prevail before the court, Obama insisted Monday that the health care law is working and that the justices "will play it straight" and leave the law intact.

    Should he lose, he added: "Congress could fix this whole thing with a one-sentence provision."

    Obama's assessment of the case against the five-year-old Affordable Care Act came as the high court prepares to announce a decision sometime later this month that could wipe out health insurance for millions of people.

    His remarks, made during a news conference at the end of a two-day international summit in Germany, also came ahead of his appearance Tuesday at the Catholic Hospital Association Conference in Washington where he was scheduled to discuss the consequences of the health care overhaul.

    In declaring that Congress could address an adverse decision by the Supreme Court, Obama is betting that an angry public would demand a remedy.

    At issue in the case is whether Congress authorized federal subsidy payments for health care coverage regardless of where people live, or only for residents of states that created their own insurance marketplaces. Nearly 6.4 million low- and moderate-income Americans could lose coverage if the court rules people who enrolled through the federal site weren't eligible for the subsidies.

    Twenty-six of the 34 states that would be most affected by the ruling have Republican governors, and 22 of the 24 GOP Senate seats up in 2016 are in those states.

    Obama also took a jab at the Supreme Court for even considering the case, arguing that the intent of Congress was to provide subsidies under state or federal exchanges.

    "Frankly, it probably shouldn't even have been taken up," he said.

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    Barack Obama

    President Obama uttered more than 3,600 words on the stage of Washington's Marriott Wardman Park ballroom on Tuesday, but his message could be summed up in three: You wouldn't dare.

    He was speaking not to the hundreds of hospital administrators assembled for the Catholic Health Association's conference but to five men not in the room: the conservative justices of the Supreme Court, who in the next 21 days will declare whether they are invalidating the most far-reaching legislation in at least a generation because of one vague clause tucked in its 2,000 pages.

    Obama's appeal to the justices, devotees of judicial modesty all: Do they really wish to cause the massive societal upheaval that would come from killing a law that is now a routine part of American life?

    "Five years in, what we are talking about is no longer just a law. It's no longer just a theory. It isn't even just about the Affordable Care Act or Obamacare," he said. "This is now part of the fabric of how we care for one another. This is health care in America."

    Without mentioning the looming decision, Obama warned of its devastating potential. "Once you see millions of people having health care, once you see that all the bad things that were predicted didn't happen, you'd think that it'd be time to move on," 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."

    The appearance had been scheduled long ago, but White House officials elevated the importance of the speech to keep pressure on the Supreme Court, which Obama said at a news conference in Germany on Monday shouldn't have even taken up the case. Obama said trashing the federal health-care exchanges, as a hostile Supreme Court ruling would do, is "not something that should be done based on a twisted interpretation of four words."

    Supreme Court Building United States US

    The conservative justices, like conservative critics of the law generally, are unlikely to be persuaded by Obama's recitation of the merits of the law, which he repeated at length Tuesday. But they may well be reluctant to upend a law that now has broad acceptance in American society.

    The Kaiser Family Foundation, which tracks public opinion on the matter, found in April that more Americans had a favorable view of the law than an unfavorable view (43 percent to 42 percent) for the first time since 2012. That difference is not statistically significant, but the favorable view is up 10 points since the botched rollout in 2013 and the unfavorable view is down seven points. Forty-six percent favor keeping the law as is or expanding it, compared with 41 percent who favor scaling it back or repealing it.

    More evidence of the acceptance of Obamacare: Health care is fading as an issue. Gallup found last month that only 5 percent called it the country's most important problem. That compares with 26 percent in September 2009.

    Certainly, those numbers could change if premiums jump as expected. But the recent improvement in the law's standing comes even though most Americans aren't aware that the law has cost the government less than forecast.


    With such broad acceptance of (if not fondness for) the new health-care status quo, it's difficult to imagine the Supreme Court justices taking away health coverage for 6 million or 7 million Americans, causing costs to skyrocket for millions of others, and likely plunging the entire American health-care system into chaos. That's not just judicial activism — it would be a judicially induced cataclysm.

    Such a cataclysm has no place in the catechism of Sister Carol Keehan, head of the Catholic Health Association and a key early supporter of Obamacare who broke with the Catholic bishops to support the law.

    "It would be unspeakably cruel," she said when I asked her after the conference Tuesday what an adverse Supreme Court ruling would produce. Millions of people — pregnant women, cancer victims, heart patients — would lose coverage, she said. "The panic is going to spread, the confusion. It's going to be incredibly chaotic." And, with Congress unable to agree even on little things, the chaos would persist.

    "It makes me crazy just to think of it," Keehan said, urging me to "light a candle" as the justices prepare their opinion.

    I'll leave the votive offering to Sister Carol. I have faith that the conservative justices, even if they detest Obamacare, have no wish to throw the country into chaos.

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    trapeze new york school

    Simon Rothman, a partner at venture capital firm Greylock, said something really interesting in regards to workers and worker benefits in the new tech economy.

    He floated the idea of a new class of worker.

    "I think this new class of worker has to reflect this new type of work that's being done,"Rothman said. "If you decouple the benefits, if you decouple the pension so it's not tied with you, think about the control you can have, going out of the networks as you wish, controlling the what and when of your job."

    Rothman is an investor in Sprig, a meal delivery app that uses independent contractors — who don't get benefits like health insurance from the company — rather than employing them directly. This is a characteristic of many businesses in the sharing economy.  The future of these companies, however, is in danger thanks to several lawsuits currently working their way through the courts, which allege that the use of these "1099 workers" is illegal, because they are treated like employees.

    Rothman thinks there needs to be a new kind of worker, unlike the "1099" independent contractor with no benefits and unlike the full-time worker collecting benefits from their employer. This worker would get her benefits like healthcare and retirement savings from somewhere else, besides her employer, freeing her up to be secure in her quest to work for lots of different companies doing lots of different things in the new tech economy.

    This is a major point. There really isn't any reason that benefits should be tied to a person's employer. The only reason we have the current system in the US is because back in the 1940s, providing health insurance for an employee was a good way to get around the World War II-era government limits on wages.

    But if an employer doesn't provide these benefits, who will?

    It seems like we need a large, national entity that is capable of broad-based collection of revenues, and the distribution of those revenues in the form of benefits like healthcare and retirement funds.

    Silicon Valley might be able to create that entity. Why? Because we already have it. It's called the government, and it has the added benefit of never having the possibility of going bankrupt. Take the Affordable Care Act, which now allows people to maintain health care coverage without being tied to an employer. Uber's Travis Kalanick previously told BuzzFeed that Obamacare was "huge" for his company and the growth of the sharing economy. 

    What Silicon Valley seems to be after here is a good, old-fashioned social safety net. The key to the riches of the sharing economy might just be big government.

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    healthcare affordable care act sign

    Any day now, the Supreme Court will announce its decision in King v. Burwell, the latest high-stakes fight over the Affordable Care Act. If the government loses, more than 6 million residents of the 34 states that declined to establish their own health-care exchanges could lose subsidies that help them purchase insurance.

    In principle, those 34 states could restore subsidies by creating their own insurance exchanges. Political leaders will certainly come under intense pressure to do so, although time is short to get an exchange up and running for 2016. Given the potential need for swift action, do the states have contingency plans in place? Could they move quickly in the wake of an adverse decision?

    To investigate these questions, we undertook, with financial support from the Commonwealth Fund, a study of five states that could lose tax credits: Florida, Michigan, New Hampshire, North Carolina and Utah.

    What we found was both striking and worrisome. Dozens of interviews conducted by our research team with political leaders, agency officials and advocacy organizations in those states indicate that the states are almost completely underprepared for the Supreme Court's decision in King. As North Carolina Gov. Pat McCrory (R) said in March, "There's no B plan."

    The difficult politics surrounding health-care reform make it hard for either Democrats or Republicans to engage in serious planning. Democrats don't want to get ahead of the Obama administration or signal to the Supreme Court that a ruling will not have major consequences. Republicans, who control at least one house in the legislature in all but three of the 34 states that use the federal exchange, told us that while they fear being blamed if people lose insurance, they also worry about the political repercussions of supporting any element of Obamacare, including the creation of a state exchange.

    The safest approach is to sit tight. Pennsylvania and Delaware are the only states whose leaders have indicated they will create a state exchange if the government loses in King. An exchange bill is currently before the Maine Senate after having passed the House. Of the states we examined, New Hampshire is best positioned to move quickly after the ruling comes down in King. Some policymakers there hope to pass a law — nicknamed the "magic wand"— that simply declares the federal Web site to be a state-based exchange within New Hampshire's borders.

    In each of the five states, political resistance to new exchanges is expected to be fierce. The speaker pro tempore in the Florida House of Representatives, for example, told us that "Florida has no desire to create a state-based exchange," even if the government loses in King. Republicans' recent rejection of Medicaid expansion suggests that they aren't bluffing.

    Legislators in Michigan believe that any discussion of a state exchange could spur a resurgence of the tea party, whose opposition doomed Republican Gov. Rick Snyder's original effort to create an exchange. And the leader of the North Carolina Senate is an ardent foe of the Affordable Care Act.

    Timing is another concern. State policymakers don't know when they would need to make tough decisions. When will the court's ruling go into effect, and when will people lose coverage? Will Congress pass a temporary patch? If so, how long will it last?

    Policymakers also expressed frustration with the Obama administration's silence about its plans. Most states expect the administration to make it easier for them to transition to state exchanges. But they are reluctant to make concrete plans when they don't know what the federal government expects of them.

    In the states that have failed to lay the groundwork, it will probably be impossible to set up an exchange in time for 2016. Open enrollment for next year is scheduled to begin this fall, meaning insurance companies proposed rates to state regulators months ago. Even with the full-throated support of the political establishment, many leaders said they would need at least 12 to 18 months to create a new exchange.

    Compounding the timing challenge, only one legislature of the five states we studied (Michigan), and eight of the 34 affected nationally, will be in session after the court's ruling. Although a special session appears likely in Utah, creating an exchange may not be on the agenda. It's far from clear that special sessions will be called elsewhere.

    There is some reason for mild optimism. Moderate Republicans, we were told, might support a state exchange if the alternative is that many of their constituents lose their coverage. And the governor in each of the five states is expected to be more supportive of creating an exchange than their legislatures.

    But the bottom line is grim. The states aren't prepared for King, and any debates over whether to create state exchanges will be turbulent and difficult. In the meantime, millions of people stand to lose their health insurance.

    David K. Jones is an assistant professor at the Boston University School of Public Health. Nicholas Bagley is an assistant professor of law at the University of Michigan.


    This article was written by David K. Jones;Nicholas Bagley from The Washington Post and was legally licensed through the NewsCred publisher network.

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    Male DoctorNEW YORK (Reuters) - As the U.S. Supreme Court prepares to rule on whether people in 34 states can continue to receive Obamacare health insurance subsidies, economists are projecting billions of dollars in lost healthcare spending for hospitals, drugstores and drugmakers if the justices say the payments are illegal.

    The immediate consequences of such a ruling would fall on the 6.4 million people who receive the subsidies and live in states that did not establish their own insurance exchanges under President Barack Obama’s healthcare law, instead relying on the federal website.

    The case, known as King v Burwell, would not affect subsidies in the District of Columbia or in the 13 states that run their own exchanges. The decision is expected sometime this month.

    Health economists calculate the economic impact of a ruling against the subsidies in different ways, but one thing many agree on is that about two-thirds of people who receive subsidies through would drop their insurance altogether rather than foot the entire bill.

    Businesses that have benefited from spending by the newly insured would take a hit, though estimates of the lost revenues vary significantly based on which assumptions are built into the calculation.

    For instance, a Kaiser Family Foundation economist put the 2015 figure at about $15 billion, based on the proportion of insurance premiums that are earmarked solely for medical costs under the healthcare law.

    "There will absolutely be these second-order effects," said Larry Levitt, a senior vice-president and healthcare researcher at the Kaiser Family Foundation. "A reasonable assumption is that (spending on) healthcare by people who lose their existing subsidies will drop by at least half."

    That would represent about $7.5 billion in spending on hospitalizations, doctor visits and prescriptions, depending on the baseline estimate.

    Another rough estimate based on 2014 medical claims data and 2015 government enrollment data, suggests the federal marketplace states will see about $22 billion in healthcare spending this year among Obamacare plan holders assuming subsidies remain in place, according to Katherine Hempstead, a director at the Robert Wood Johnson Foundation. The majority of Obamacare members receive subsidies.

    Health policy experts who are critical of the law have taken a different tack, focusing more on the potential financial returns to individual citizens if the Supreme Court ruling exempts them from penalties for not having insurance. 

    Conservative economist Douglas Holtz-Eakin and Brittany La Couture of the American Action Forum wrote recently that such a ruling could give a boost to small businesses by removing requirements on employers to provide health coverage.

    Joseph Antos of the right-leaning think tank American Enterprise Institute says the estimates of healthcare spending effects are imprecise at best. He expects that a ruling invalidating the subsidies would be followed by a "fix" in which Congress or states somehow restore subsidies, at least temporarily.

    In that case, he said, any drop in healthcare spending would be temporary and only "a very minor downward bump."

    "They are going to extend the subsidies in some manner," Antos said. "I don't know how they are going to do it, but they are going to find some way." 

    The Affordable Care Act is one of the most politically divisive U.S. laws, opposed by many Republicans. Party lawmakers have fought in particular against its requirement that all Americans have health insurance or pay an annual penalty, and say they have plans to replace the law if the subsidies are ruled out.



    Without a legislative fix, however, policy experts and Wall Street analysts expect hospitals will take the biggest hit, as they bear the brunt of costs for patients who must be treated but can’t pay their own medical bills. Hospital associations said an increase in such costs could “devastate” some of their members, according to a brief filed with the Supreme Court.   

    When Obamacare was conceived, hospitals were so confident that newly insured patients would increase their revenues that they agreed to $269 billion in cuts to the government’s Medicaid and Medicare health plan reimbursement over 10 years.

    "It was a quid pro quo, with hospitals agreeing to these reductions in return for coverage of more people," said Kevin Brennan, executive vice-president for finance at Geisinger Health System in Pennsylvania, which relies on

    Geisinger offers an insurance plan through the Obamacare exchange and estimates that 80 percent of the 22,000 people who hold those polices receive subsidies.

    Pennsylvania is one of a handful of states that plans to set up its own exchange if the Supreme Court rules against the subsidies, and has said it could be ready for 2016.

    Data from publicly-traded hospital operators show their costs for treating uninsured patients have dropped since Obamacare took full effect in 2014. 

    In the first half of that year, admissions of "self-pay" patients, who are almost always uninsured and unable to pay the full bill, fell 14.7 percent at Community Health Systems, 6.6 percent at HCA  Holdings, 6.5 percent at Tenet Healthcare Inc, and 9.3 percent at Universal Health Services, according to an analysis by consultants at PwC.   

    Drug companies like Pfizer and Merck & Co and medical device makers such as Medtronic agreed to new taxes in exchange for the expected increase in paying Obamacare customers. The bet has paid off: Pharmacy benefits manager Express Scripts Holding Co estimates that each Obamacare patient now accounts for an average of $79 per month in prescription drug spending.

    That works out to roughly $6.1 billion a year for the 6.4 million people whose subsidies would be eliminated.

    Not all of the $6.1 billion would dry up, since drug spending by the uninsured is not zero, said Rand Corporation economist Christine Eibner, who has studied healthcare utilization by Obamacare patients. "On average, people will not fill as many prescriptions" if losing their subsidies causes them to drop their insurance, she said. 

    Insurers will see a more limited hit to revenue if the subsidies are thrown out, largely because Obamacare customers are only a small percentage of any single health insurer’s total business. At the nation's largest insurer, UnitedHealth Group, for instance, about 1 percent of its 46 million members are receiving subsidies that are at risk.


    (Reporting by Caroline Humer and Sharon Begley; Editing by Michele Gershberg and Sue Horton)

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    john boehner

    Congressional Republicans will move to temporarily continue health care subsidies for millions of people if the Supreme Court overturns the aid, according to plans discussed in the House and Senate Wednesday.

    Republicans on both sides of the Capitol met privately to discuss how to respond to the politically explosive ruling that's expected in the next two weeks and could result in some 7 million people losing subsidies to buy coverage under President Barack Obama's contested health care law.

    Under the plan presented by a quartet of committee chairman to House Republicans and described by several lawmakers, subsidies would continue for the remainder of this calendar year. After that, states could obtain block grants to continue the aid; if a state turns down the block grant, individuals could receive tax subsidies directly as they do now.

    The money would be used to shop for health insurance in a reordered marketplace without requirements for most people to carry insurance and most employers to offer it. The plan would be temporarily, although how long exactly it would last was unclear; several lawmakers said it would be no more than two years.

    After that, the law Republicans call "Obamacare" would be eliminated altogether and replaced with a new approach.

    Senate Republicans are discussing a similar structure although fewer details were available.

    Such an effort would be sure to encounter solid Democratic opposition and a veto from the president, who has championed the law's extension of health coverage to millions.

    And the approach carries political risks for the GOP. In the House, Republicans have voted more than 50 times to repeal all or portions of the health care law and could now be accused of moving to extend it leading into a presidential election year.

    A number of House conservatives have already expressed opposition to extending the law's subsidies in any way, shape, or form. GOP leaders are hoping to use a court victory by conservatives challenging a key girder of Obama's law to take the political offensive against the statute, and to avoid blame from voters should the subsidies be erased.


    Rep. Dennis Ross, R-Fla., said House GOP leaders argued that the situation presents an opportunity for Republicans.

    "This is transitioning out of Obamacare, not repealing it and not even affirming it. It's transitioning," Ross said. "I think at the end of the day when we realize that we have one opportunity to respond and that Congress will be the focus of that response, we have to be together and do that, I think that that may carry the day. It's going to take a lot of coalescing."

    A leading author of the evolving Senate approach, Sen. John Barrasso, R-Wyo., said it would help people now receiving subsidies through the 2016 elections, when the GOP hopes to capture the White House and keep congressional control.

    "We need to fix health care in America, but Obamacare cannot be fixed," Barrasso told reporters.

    Some conservatives say the subsidies should be completely ended, not extended, and the entire law dismantled.

    "I do not believe we should extend subsidies. I think the proper answer is to allow states to opt out" of the law's requirements, said Sen. Ted Cruz, R-Texas, a candidate for his party's presidential nomination.

    The high court is expected to rule in the next two weeks on a lawsuit brought by conservatives and backed by the GOP. They say that under the law, the aid is limited to states operating their own insurance marketplaces, and is not allowed for the roughly three-dozen that use the federal website.

    Democrats say the overall bill's context makes clear that the subsidies were designed to go to residents of every state.

    In the 34 states likeliest to be hit hardest — should the justices erase those subsidies — about 6.4 million people receive the aid, averaging $272 monthly, according to the Health and Human Services Department. Analysts have warned that most of those people would no longer be able to afford health coverage if the assistance was ended.

    Many Republicans say since Obama would not let them kill his own law, a complete overhaul will have to await the 2016 elections, when the GOP hopes to capture the White House and retain congressional control.

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    Jumaane Cook (bottom R), age 5, of Cleveland, Ohio stands with his father James Cook (obscured, holding sign at R) as they join Obamacare supporters demonstrating at the Supreme Court building in Washington March 4, 2015. REUTERS/Jonathan Ernst

    BOSTON/NEW YORK (Reuters) - U.S. lawmakers and governors are unlikely to act to restore Obamacare health insurance subsidies in at least 34 states should the Supreme Court rule them illegal, health policy experts said on Wednesday.

    The influence of elections in 2016 as well as restrictions already put in place in states opposed to President Barack Obama's health law could hamper even a short-term compromise, experts said during a panel discussion in Boston at The Forum at Harvard T.H. Chan School of Public Health, presented in collaboration with Reuters.

    Their views run counter to the optimism expressed by many Obamacare watchers, from Wall Street investors to healthcare executives, who are betting either Congress, the White House or individual states could come up with a fix to keep the subsidies flowing to nearly 6.4 million people.

    Without subsidies, millions of people could drop their insurance plans and prices of other individual plans could then rise, pushing millions more Americans out of the market. People unable to afford insurance could be exempt from the law's mandate to have insurance, undermining a key component of the healthcare reform law.

    The Supreme Court is expected to rule on the case, known as King v Burwell, in the next two weeks. The challenge, brought by libertarian opponents of Obamacare, argues that the law only allows subsidies in states that have set up their own exchanges to sell health insurance, rather than rely on the federal website.

    If the court decision requires the government to stop paying these subsidies, Republicans may offer some sort of legislation to reinstate them, but are likely to require other concessions that Democrats, including Obama, would refuse to consider. They might include throwing out the law's individual mandate that requires most Americans buy health insurance or pay a fine.

    "The Republicans will send something to the president who will reject it," Douglas Holtz-Eakin, president of the conservative American Action Forum, said during the discussion. "There will be a period of stand-off."

    Harvard professor Robert Blendon compared the potential wrangling in the aftermath of a Supreme Court decision to unsuccessful efforts to broker even an interim agreement between warring factions in the Middle East process.

    "The dilemma is that both parties are going to think it's smart not to reach an agreement," Blendon said. "What's too bad is that we actually could reach a compromise through the (2016) election, and that's what people who care about this should be working on."

    The White House has said there is no "Plan B" to continue subsidies should the court invalidate them, and that it is up to the states and Congress to find a fix.

    But many of the states using decided against setting up an Obamacare exchange because their Republican leaders oppose the law. Some have sought its repeal.

    There is a "distinct lack of political will" to embrace any part of Obamacare in states like Texas, which are also home to the largest numbers of uninsured people in need of subsidies, Harvard professor John McDonough said.

    A decision against the government would likely come up in the 2016 elections. "A lot of people will be voting on this issue," McDonough said.

    A replay of the discussion is available at

    (Editing by Tom Brown)

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    The Supreme Court will soon announce its decision in King v. Burwell, a case that could have far-ranging impact on the Affordable Care Act. The system more commonly known as Obamacare pays subsidies to taxpayers below 400 percent of the poverty line to cover health-insurance premiums. The plaintiffs in King argue that the explicit language of the law forbids subsidy payments to those purchasing health insurance outside of a state exchange.

    If the Supreme Court decides to follow the explicit textual language of the ACA, people in 34 states could end up with skyrocketing premiums and no way to pay them. That portends disaster not just for those taxpayers who have to comply with the first-ever federal mandate to buy insurance regardless of any other interaction, it will deliver a body blow to the medical industry as well, Business Insider reports. “[E]conomists are projecting billions of dollars in lost healthcare spending for hospitals, drugstores and drugmakers if the justices say the payments are illegal.”

    With this potential for massive disruption approaching, the media have rushed to the accountability barricades by demanding a solution to the debacle from… Republicans. Bear in mind that Obamacare famously became law by using parliamentary tricks in which Democrats in Congress got around the fact that not a single Republican would vote for it. At the time, Nancy Pelosi bragged that Americans wouldn’t know what the ACA contained until Democrats shoved it past Republicans and onto Barack Obama’s desk for his signature.

    Republicans now control Congress, largely on the unpopularity of Obamacare and especially the individual mandate that sets up this trap. Democrats wrote the language in question to force states into adopting the cost of the exchanges, as Obamacare architect Jonathan Gruber publicly admitted, so the backfire on this belongs entirely to Democrats. If the Supreme Court rules for the plaintiffs in King, the mess will drop into their laps, but that doesn’t mean they have to draft the solution to it. Many of the same Democrats responsible for this debacle still serve in Congress – Nancy Pelosi and Harry Reid, especially – and the media should be pressing them for their solution to the disaster they created, along with an explanation of how they’ll craft one Republicans can support.

    The same media dynamic has taken place in the nascent presidential primary. Republican candidates have to occasionally field questions about how they’ll fix Obamacare when most of them have gone on the record to note that they want to repeal it. The media doesn’t offer nearly the same amount of pressure on Democratic candidates to explain how they’ll fix a Democratic mess, but Hillary Clinton has offered a couple of hints anyway – at least indirectly.

    First, rather than address the systemic dysfunction of Obamacare, Hillary wants to make it even larger and costlier than it is now. In an interview with the Des Moines Register, Hillary pledged to defend the ACA, but to fix its shortcomings. She promised to “fix the family glitch,” and “to deal with the high cost of deductibles that put such a burden on so many working families, and how to deal with the exploding cost of drugs, particularly the so-called specialty drugs."

    However, both the family glitch and the high deductibles were deliberate choices by Democrats in the ACA. Both were trade-offs to keep premiums low, and therefore minimize the cost of the subsidies. The former only came to light in 2013, just before the disastrous rollout of the exchange. Essentially, it boils down to the employer mandate to keep insurance plans affordable for employees, capping their contributions to 9.5 percent of income – but Congress deliberately didn’t extend that to family coverage. Workers who have access to such insurance through employers can’t qualify to buy subsidized insurance for their families in ACA exchanges.

    That was a deliberate cost-cutting measure by Democrats, Chris Jacobs of America Next reminded Wall Street Journal readers. “To keep the total cost of insurance subsidies ... under $1 trillion, lawmakers made numerous tough choices,” Jacobs recalls. They delayed the start of subsidized insurance for a year, and put curbs on levels of subsidies in the later years of the ACA’s first decade. “And Congress passed—whether lawmakers knew it or not—the “family glitch” provision.”

    The need for higher deductibles was an even more explicit choice. Obamacare mandates higher risks for insurance pools, both in terms of eliminating barriers for pre-existing conditions and for preventive-care coverage. Insurers had to either hike premiums significantly to deal with the increased access or raise deductibles to force the costs back onto the consumer. The same tough choice that Jacobs notes in terms of holding subsidy costs below $1 trillion forced the Obama administration to pressure insurers into keeping premiums low, which meant either higher deductibles or bankruptcy. Anyone with even a passing understanding of risk pools could have easily predicted these outcomes.

    Hillary remained notably silent on exactly how she would rework the ACA to undo the family glitch and lower deductibles, and especially how she would pay for the enormous increase in program costs that will result. Her campaign tipped their hand on their approach to fiscal problems earlier this week in announcing their schedule for releasing policy proposals. “Among these proposals,” press secretary Brian Fallon tweeted, “will be revenue enhancements.” As the Washington Examiner’s Jason Russell noted. “Revenue enhancements” is a euphemism on the same level as Bill Clinton’s use of “broad-based contributions” – tax hikes.

    In the end, it may not matter what the Supreme Court decides on King v. Burwell. Democrats created a disaster far broader than the issue of subsidies in the federal exchange. The only solution Hillary and other Democrats have on the ACA are the massive tax hikes needed to fund the monster of government-mandated health insurance. Hillary can use all of the euphemisms for this she can find, but in the end Obamacare will bleed taxpayers dry.

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    obamacare Later this month, the Supreme Court is set to hand down a decision on the second major challenge to the Affordable Care Act, commonly referred to as Obamacare. 

    King v. Burwell revolves around whether the Obama administration is entitled to provide healthcare subsidies to millions of Americans living in the 36 states that didn't set up healthcare exchanges on their own. 

    Several conservative activists brought the case after they discovered that four words in the law appear to suggest that healthcare subsidies wouldn't be allowed in states that didn't set up their own exchanges. The law itself says that subsidies can be provided through exchanges "established by the state."

    If the court sides with the plaintiffs, millions of Americans in states that did not set up their own exchanges will essentially forfeit or be forced off of their plans because the federal government won't be able to subsidize their insurance anymore. 

    To illustrate which states would be hit hardest, we've collected maps that show the impact that Obamacare has had on the insurance landscape.

    More Americans have insurance now than before Obamacare

    This Metric Map shows the percentage of uninsured Americans in each state in 2010, before the Affordable Care Act passed. The red shows high percentages, while green signifies the lowest. As you can see, the percentage of uninsured people was relatively high in the Southern states. 

    screen shot 2014 10 29 at 6.42.29 pm

    Before the law's passage, the number of uninsured rose to record highs. In 2006, the percentage of uninsured hit an all-time high of 16% with close to 44 million Americans lacking insurance. 

    The ACA has vastly increased the number of Americans who have health insurance. By the end of this year's open enrollment period, 11.7 million Americans signed up for insurance under Obamacare, according to figures released by the Obama administration. As CNN notes, fewer than 12% of Americans are now uninsured.

    As you can see from this map, there are only a handful of "red" states with high percentages of uninsured people in a post-Obamacare world. The below map could look a lot different if the Supreme Court rules for the Obamacare challengers. 

    obamacare insurance map

    This county-specific map by Enroll America shows the number of counties with high percentages of uninsured.

    Here's what the map looked like in 2013. The dark blue areas had an uninsurance rate higher than 10%. 

    health insurance map

    The next year, the shift was huge. See the county-specific info here.

    health insurance map

    An anti-Obama ruling would likely hit the South hardest

    One of the great ironies that Obamacare advocates point out is that many of the states that stand to benefit from Obama's healthcare law also oppose it.

    As The Washington Post points out, virtually no states in the South accepted money from the federal government to set up their own state exchanges.

    Maps from the Washington Center for Equitable Growth show that many of the counties that stand to benefit the most from subsidies lie in poor southern states like Mississippi, which declined to set up a state exchange.

    healthcare subsidies

    This is what makes the stakes so high for the case. Many of the counties with the highest percentage of residents eligible for subsidies are also in states that have refused to set up their own healthcare exchanges.

    obamacare mapAs data mapped by the Kaiser Family Foundation show, states including Texas, Florida, and Mississippi have some of the highest numbers of subsidy recipients who would see huge increases in premium cost if the subsidies disappeared.

    This would likely force thousands of healthy younger subsidy recipients to drop out, which would eventually raise premium rates for older recipients. Scroll down to view the interactive map.

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    lynch comeyThis week the Department of Health and Human Services (HHS), the Department of Justice (DOJ), and local law enforcement in 17 different US cities arrested 243 individuals for an alleged $712 million in fraudulent Medicare charges.

    The nationally coordinated bust is the largest ever for the Medicare Fraud Strike Force, "both in terms of the number of defendants charged and loss amount,"according to the FBI.

    “These are extraordinary figures,” said Attorney General Loretta Lynch at a press conference. “They billed for equipment that wasn’t provided, for care that wasn’t needed, and for services that weren’t rendered.”

    Court documents allege that Medicare claims were submitted for unnecessary procedures that often were never even provided, and that, in some cases, Medicare beneficiaries were paid cash kickbacks for providing their information to healthcare providers who submitted fraudulent claims.

    “The people charged in this case targeted the system each of us depends on in our most vulnerable moments,” said FBI Director James B. Comey in a press release. “Health care fraud is a crime that hurts all of us and each dollar taken from programs that help the sick and the suffering is one dollar too many.”

    The press release explained how the FBI was able to collect and analyze vast sums of data on Medicare and to deploy rapid-response teams where the data showed fraud. “In these cases, we followed the money and found criminals who were attracted to doctors offices, clinics, hospitals, and nursing homes in search of what they viewed as an ATM,” said Comey.

    The FBI press release detailed the cases in three of the worst offending cities:

    • In Miami, 73 were charged in schemes involving about $263 million in false billings for pharmacy, home healthcare, and mental-health services.
    • In Houston and McAllen, Texas, 22 were charged in cases involving more than $38 million. In one case, the defendant coached beneficiaries on what to tell doctors to make them appear eligible for Medicare services and then received payment for those who qualified. The defendant was paid more than $4 million in fraudulent claims.
    • In New Orleans, 11 people were charged in connection with home healthcare and psychotherapy schemes. In one case, four defendants from two companies sent talking glucose monitors across the country to Medicare beneficiaries regardless of whether they were needed or requested. The companies billed Medicare $38 million and were paid $22 million.

    Dept_of_JusticeThe DOJ alone has recovered more than $15 billion in healthcare-fraud-related cases in the last five years. Strike Force cases reportedly result in an average sentence of four years, with some cases resulting in 50-year bids. To date, defendants include some 200 doctors and 400 medical professionals who have been charged by the Medicare Fraud Strike Force.

    "This record-setting takedown sends a message to would-be perpetrators that health care fraud is a risky way to line your pockets," US Department of Health Inspector General Daniel Levinson stated. "Our agents and our law enforcement partners stand ready to protect these vital programs and ensure that those who would steal from federal health care programs ultimately pay for their crimes.”

    The Medicare Fraud Strike Force has charged over 2,300 defendants for more than $7 billion in suspected fraudulent charges since its establishment in 2007.

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    obamacareRepealing President Obama's signature healthcare law will likely come with a pricetag in the billions. 

    Some conservative activists are hoping that the Supreme Court will gut Obamacare in a high-stakes opinion that will be handed down before the end of June.

    But deficit-hawks within the party may be less than enthused about the price.

    In their first major analysis of the issue in three years, the Congressional Budget Office and the Joint Committee on Taxation said a repeal would increase the deficit, send the number of uninsured Americans soaring, and lead to higher Medicare costs.

    According to the CBO, repealing the law could increase the US budget deficit by up to $353 billion over 10 years. 

    The deficit increase could be smaller. By taking into account economic feedback from an Obamacare repeal, chiefly an increase in the supply of labor as Americans lose Obamacare subsidies, CBO and JCT estimated that the deficit would only increase by $137 billion over the 2016-2025 period.

    Perhaps more importantly, the CBO estimates that repealing Obamacare would increase the number of non-elderly Americans by 19 million by 2016 alone.

    The CBO's estimates come as the Supreme Court is set to announce whether the federal government is legally entitled to grant subsidies to Americans who live in states that haven't set up their own health care exchanges.

    Several prominent conservative legal experts brought the case after they discovered a strangely-worded phrase in the law that suggests that healthcare subsidies wouldn't be allowed in states that didn't set up their own exchanges.


    If the court sides with the plaintiffs, millions of Americans in the 36 states with federally-run exchanges will no longer qualify for subsidies. This will likely force thousands of healthy subsidy-recipients to drop out, raising premiums and forcing older, less-healthy Americans off their plans. 

    The repeal would hit poor, Southern communities hard. Since Obamacare was passed in 2010, 11.7 million Americans have signed up through state and federal exchanges, many of them with the help of federal government subsides.

    View an interactive map below via the Kaiser Family Foundation that shows how repealing the healthcare law would play out in each state:


    SEE ALSO: Obama: If the Supreme Court derails Obamacare, 'Congress could fix this whole thing'

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    Obamacare Protest

    Repealing the Affordable Care Act would bring higher employment but also higher deficits, according to the Congressional Budget Office.

    On Friday, the CBO along with the Joint Committee on Taxation (JCT) released a report outlining the economic and budgetary impact of eliminating the healthcare overhaul signed into law in 2010.

    The report said that, excluding macroeconomic feedback, federal deficits would increase by $353 billion over the period from 2016 and 2025.

    However, the repeal of the ACA would boost the labor supply, resulting in an average GDP increase of 0.7 percent from 2021-2025. The increased economic output would also reduce deficits by $216 billion between 2016 and 2025, largely due to a jump in taxable income.

    "All told, CBO and JCT estimate that repealing the ACA would raise federal deficits by $137 billion over the 2016–2025 period through its impact on direct spending and on revenues," the report said. "A repeal would reduce deficits during the first half of the decade but would increase them by steadily rising amounts from 2021 through 2025.

    The estimates are illustrated by the chart below, with "macroeconomic feedback" being the net gain from increased economic activity (i.e increased tax revenues).

    Congressional Budget Office ACA

    The CBO also estimated that if the ACA were repealed, the number of nonelderly Americans without health insurance would rise by 19 million-24 million people per year from 2016 to 2025.

    The report comes as the Supreme Court is expected to rule this month on King v. Burwell, a highly anticipated case that questions whether the IRS has the right to extend healthcare subsidies for coverage purchased on federal exchanges. The plaintiffs argue that the law only allows tax credits for coverage purchased on the state-run marketplaces.

    It is important to note, however, that the CBO's estimates reflect the cost of a full repeal of the law and not the results of a Supreme Court ruling.

    The report said:

    CBO and JCT’s baseline projections and the estimates in this report reflect the way the law is currently being implemented, with subsidies available through all exchanges, but the Court could rule that the law does not authorize subsidies in some states. If that happened, CBO and JCT would reduce their projections of spending on those subsidies under current law and would reduce their estimates of the savings generated by repealing the ACA’s coverage provisions—although the magnitude of those reductions is uncertain and would depend in part on the specific details of the Court’s opinion.

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    Anthony Kennedy Scotur

    The fate of the Affordable Care Act is in the hands of the Supreme Court once again — and whether it lives as is or crumbles might depend on a justice who believes the heart of the law to be unconstitutional.

    Justice Anthony Kennedy is the traditional swing vote, and his views on the latest death threat to the law colloquially known as Obamacare will likely predict how the court rules.

    The fate of the decision could also rest with conservative Chief Justice John Roberts, who previously sided with the liberals to uphold the law.

    This latest challenge puts Kennedy in a particularly vexing position.

    Just three years ago, he voted against the government and opined that the heart of the Affordable Care Act — its individual mandate requiring individuals to purchase some form of health insurance or pay a penalty — was unconstitutional. Kennedy read his dissent from the bench with a palpable display of emotion after Roberts joined the liberals to save the law.

    "It amounts to a vast judicial overreaching," Kennedy said of the 5-4 decision that upheld the mandate's penalty as a tax.

    Now Kennedy might be the one to save a key provision of the law. This challenge, King v. Burwell, has the potential to cripple the law and throw its future into highly uncertain territory in the 36 states where the federal government provides subsidies for low-income people to buy health insurance.

    The high court's decision could be handed down as soon as Monday and is expected to be delivered sometime before the end of the month. And again, Kennedy and Roberts are the justices to watch.

    "They're going to be the swing votes," said Jonathan Adler, a professor at Case Western University School of Law and one of the lawyers instrumental in forming the challenge. 

    "And I expect them to vote together, whichever way they vote."

    The challengers in King v. Burwell are focusing on four words in the statute that supposedly suggest the federal government can't subsidize health insurance in the 36 states that refused to set up their own exchanges. Those four words are in Section 1311 of the law, which establishes insurance exchanges. That section states that subsidies should be issued to plans purchased"through an Exchange established by the State under Section 1311" of the Affordable Care Act.

    John Roberts and Anthony KennedyKennedy was the justice targeted by both the challengers and the Obama administration during oral arguments in March. And each side saw points in which they thought he was leaning their way. In one exchange, he seemed to worry about the coercing effects a decision against the healthcare law would have on states to set up their own insurance marketplaces.

    During another, he said the challengers "may prevail" on the "plain words of the statute," even though he acknowledged a "serious constitutional problem if we adopt your argument."

    Chris Walker, an assistant professor at the Michael E. Moritz College of Law who clerked for Kennedy, told Business Insider that Kennedy could go either way.

    "A lot of the questions he was asking were about federalism, and federalism is something he cares deeply about," Walker said. 

    On the flip side, near the end of the oral argument, Kennedy asked Solicitor General Donald Verrilli — who represents the Obama administration — about how much authority the IRS should have in interpreting a law passed by Congress, as Slate's Dahlia Lithwick noted. It was the IRS that interpreted the law to allow subsidies in states with exchanges set up by the federal government.

    Kennedy questioned whether Congress really meant for the IRS rather than the states to make a decision with potentially billions of dollars at stake.

    "[I]t seems to me a drastic step for us to say that the Department of Internal Revenue Service and its director can make this call one way or the other when there are, what, billions of dollars of subsidies involved here? Hundreds of millions?" Kennedy said during the oral arguments.

    "So you've got these bookends," Walker told Business Insider. "At the beginning, he seems very concerned about the federalism argument. And at the end of the argument, he seems to be concerned about executive power and congressional interpretation. So it's difficult to figure out where he stands."

    obamacare map


    Roberts is much harder to figure out, and Supreme Court observers say they're entirely uncertain which way he'll lean. On one hand, he upheld the law last time. On the other hand, he's viewed as generally pro-business in his decisions, and multiple businesses and organizations have issued briefs on the side of the administration in this case.

    Complicating things is the fact that Roberts spoke just two meaningful times during the oral arguments. That was as often as the number of times he opened his mouth to crack a joke at one of the lawyers involved in the case.

    Kennedy has been more of a talker. In fact, just three weeks after the arguments, he appeared before Congress and said something that some observers viewed as possibly tipping his hand. He said, in a general sense and without mentioning the Affordable Care Act, that the judiciary should decide cases without worrying about external factors like congressional gridlock.

    That comment spurred speculation that he might not have any qualms about dismantling Obamacare even though lawmakers might not ever come together to fix the law.

    But even Adler, one of the legal minds behind the King challenge, said those comments didn't raise his hopes.

    "Those comments in Congress were normal," Adler said. "I don't think anyone thinks the court's decision will be affected by Congress."

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    Obamacare Protest

    WASHINGTON (AP) — A nonpartisan government study says repealing President Barack Obama's signature health care law would modestly increase the budget deficit and the number of uninsured Americans would rise by more than 20 million.

    The report from the Congressional Budget Office comes ahead of a highly anticipated Supreme Court ruling that could have a major impact on the Affordable Care Act, nullifying health insurance subsidies for some 6 million people in more than 30 states. The budget analysts said that would add a host of new uncertainties to their estimates.

    Republicans now in control of both chambers of Congress say they are not backing away from their promise to repeal "Obamacare."

    But repealing the law's spending cuts and tax increases would add $137 billion to the federal deficit over the coming decade, CBO said in the report issued Friday, even though almost $1.7 trillion in coverage costs would disappear. Repeal would reduce deficits in the first few years but increase them steadily as time goes on.

    Repeal would up the number of uninsured people by about 24 million people, and the share of U.S. adults with health insurance would drop from roughly 90 percent now to about 82 percent, the report said.

    On the other side of the balance sheet, the report says that completely repealing the law would, on average, boost the economy by 0.7 percent a year after the start of the '20s. That's mostly because more people would enter the workforce or work more hours to make up for the lack of government health care subsidies.

    But the positive economic effects of repeal would fade over time, the budget agency said, offset by the increased budget deficits. Repeal of the excise tax on high-cost plans is a major reason why deficits would increase in later years, because more and more plans would be hit by this "Cadillac tax."

    obamacare insurance map

    The CBO provides lawmakers with nonpartisan budget and economic analysis. Republicans controlling Congress have increasingly asked the office to incorporate a broader range of potential economic consequences of major legislation into its work, and Friday's report is the first major study released since GOP appointee Keith Hall took over as CBO director. CBO analysts always caution that their studies of legislation can be uncertain, especially over many years.

    Previously, CBO analyses would not have taken into account such a broad range of economic consequences. The agency said that using its earlier approach would have resulted in a bigger estimated impact on the deficit, an increase of $353 billion over the coming decade. Adding the economic factors cuts the repeal's effect on the deficit by more than half over 10 years, the report says.

    The budget scorekeepers also offered a cautionary note to Congress: Obama's law is by now so enmeshed with the health care system that uprooting it would create its own issues.

    "Implementing a repeal of the ACA would present major challenges," the report said. "In the five years since its enactment, nearly every key provision of the law has taken effect and has been incorporated into final rules and other administrative actions. Undoing the ACA would thus be quite complicated."

    Unwinding changes to Medicare would be particularly difficult, the CBO said.

    The health care law offers subsidized private health insurance policies to people who don't have access to coverage on the job, along with an expanded version of Medicaid geared to low-income adults, in states that have accepted the expansion.

    If the law is repealed, about 18 million fewer people would have individual health insurance policies, and about 14 million fewer people would be covered under Medicaid, the report said. Gains in employer coverage would partially offset those losses, with 8 million more covered through job based insurance.

    About 30 million people are still uninsured, even after two full years of coverage expansion under the law.

    The study comes as Washington awaits the Supreme Court's decision on subsidies.

    In a twist, the budget office suggested that if those subsidies are curtailed, it would reduce the projected savings from repealing the rest of the law. That's because the government would not be spending money to subsidize coverage in the affected states.

    Conservatives who brought the lawsuit say the law's literal wording prevents the federal government from subsidizing private health insurance premiums in states that failed to set up their own insurance markets. Most have not done so, reflecting continued political opposition to the program. The administration argues that the law intended subsidies to be available in all states.

    The Supreme Court is expected to issue the decision by the end of June.

    Republicans in control of the House and Senate have said that if the court strikes down subsidies in the mostly GOP-held states that would be affected, they would try to advance legislation to ease the immediate effect on people who would lose coverage.

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    The Supreme Court could be about to torpedo a significant part of President Barack Obama's legacy.

    The highest US court is expected to soon issue its ruling on Obama's signature healthcare law. At stake is the legality of healthcare subsidies for millions of people who get their insurance through the federal exchange. 

    The subsidies for low-income Americans seeking mandatory healthcare insurance are widely seen as a critical component of the Obama-backed Affordable Care Act, the reform bill that passed in 2010.

    And, according to The New York Times, even Obama's closest allies admit that "a decision to invalidate the subsidies would mean years of logistical and political chaos."

    Former Sen. Majority Leader Tom Daschle (D-South Carolina), who was once Obama's pick to head the Health and Human Services Department, only gave a 50% chance that the subsidies survive the upcoming ruling. 

    Daschle used harsh terms to describe the outcome if the White House loses the case: 

    "It would be a huge, devastating blow to the country. ... It is cataclysmic, from an insurance perspective."

    Former Secretary of Health and Human Services Kathleen Sebelius agreed that such a ruling would be devastating:

    "Will that have, in the history books, an impact on the president? ... I'm sure. I know Republicans like to focus on how this would be a great blow to the president. But for heaven’s sake, they would have a mess on their hands."

    Click here to view the full New York Times report.

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    John Roberts and Anthony Kennedy

    The Supreme Court will issue a decision on President Barack Obama's signature healthcare law any day now, and Justice Anthony Kennedy made a telling comment in March that could signal how he will vote.

    Kennedy, a key swing voter, said during oral arguments that he saw a "serious constitutional" question with the interpretation of the Affordable Care Act (ACA) set forth by the plaintiffs who are trying to strike it down.

    "If that's Kennedy's view of the case, there's almost no chance that the challengers can win," UCLA constitutional law professor Adam Winkler told Business Insider at the time.

    The current fight over the ACA, King v. Burwell, centers on whether the US government can keep subsidizing insurance in the roughly three dozen states that have not set up their own insurance marketplaces. The health law laid out a plan in which states set up their own exchanges but said the federal government could step in and set up the exchanges for the states if they could not do it on their own.

    Opponents of the law point to a part of the statute that they say suggests people can't receive subsidies unless the state set up their insurance marketplace. That part of the law says that subsidies should be issued to plans through an exchange "established by the state."

    supreme courtIf the opponents win, people in those states would lose their subsidized health insurance unless the states set up their own exchanges.

    Kennedy appears to have a problem with that scenario because it would effectively coerce states into setting up their own exchanges if they wanted their citizens to have insurance. Kennedy doesn't like that, because he is a big fan of federalism.

    “There is a serious constitutional problem here if we adopt your position," Kennedy told the lawyer for the plaintiffs, according to The New York Times.

    From SCOTUSblog:

    Simply put, Kennedy expressed deep concern with the federalism consequences of a reading that would coerce the states into setting up their own exchanges to avoid destroying a workable system of insurance in the state.

    The high court will issue its opinion as early as Thursday, and all eyes will be on Kennedy and Chief Justice John Roberts, a conservative who surprised everybody in 2012 when he voted to save Obamacare.

    In the 2012 case, Roberts upheld the heart of Obamacare, a mandate that people buy health insurance or pay a penalty. Roberts ruled that the penalty was the equivalent of a tax and thus constitutional.

    In that case, Kennedy signed onto a lengthy dissent finding that Congress had exceeded its authority in mandating that Americans buy health insurance or pay a penalty.

    While Kennedy voted to destroy Obamacare just a few years ago, he may end up saving it this time around.

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    SCOTUSblog Twitter account

    Every year when the Supreme Court gets ready to hand down important decisions, people start tweeting frantically at @SCOTUSblog, which many believe is the official Twitter account of the Supreme Court.

    There's one problem: the Supreme Court doesn't have an official Twitter account, and the impassioned Twitter users are tweeting at a blog that has no affiliation with the Supreme Court.

    But instead of tuning out the misplaced tweets, SCOTUSblog— a popular legal blog that covers the court — is hilariously sending comebacks to the most ridiculous tweets.

    The blog sarcastically responded to numerous passionate tweets that appeared to be directed at the high court.

    On Monday, SCOTUSblog waded right into a host of controversial issues from the past several court terms, and subtly reminded tweeters that it is not the Supreme Court.

    SCOTUSblog took on both sides of the marriage equality case that's expected to come down in the next week.

    The blog also took the time to correct misinformed users incensed by the possibility that the court could overturn a key part of the Affordable Care Act that allows the federal government to grant healthcare subsides to low-income Americans.

    SCOTUSblog also addressed claims that the high court is racist. 

    SCOTUSblog claimed some credit for controversial Supreme Court decisions, including the controversial Citizens United ruling that vastly expanded political spending.

    Finally, the blog reminded people repeatedly that it is still not the Supreme Court. 

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