By Marina Renton
As a public health major at Brown University, I’ll admit I’m biased: When the King v. Burwell decision was handed down this week, I was absolutely elated. The decision felt exactly right to me; people were not going to lose their health care coverage, and some might even have the chance to gain subsidized insurance.
But the case is complicated, so to really understand the take-home messages, I consulted a couple of health care policy.
One is Ira Wilson, professor of Health Services, Policy and Practice at Brown University, who taught my “Health Care in the United States” class last semester.
The other is Michael Doonan, assistant professor at Brandeis’ Heller School for Social Policy and Management and executive director of the Massachusetts Health Policy Forum
Their responses are lightly edited:
MR: What background do we need to understand the Supreme Court decision?
IW: One of the core tenets of health care reform is that people who can’t afford insurance get subsidies so that they can buy it.
•reforms insurance by doing things like preventing denials due to pre-existing conditions. So it requires that insurance do certain things that it hasn’t always done in the past.
•requires that everybody get insurance. That’s the individual mandate, and that was covered in the 2012 challenge and then upheld in the 2012 case.
•requires that affordable insurance be available to everyone. And this King case threw into question that third leg of the stool as it were. Or at least it brought it into question for the states that, rather than deciding to develop their own exchange, used a federal one. So without this, the entire framework for health care reform in those states that have a federal exchange begins to fall apart. And as we know because we’ve seen lots of articles about estimating how many people would lose insurance if those subsidies were taken away (estimates were in the six million range), it would have a devastating impact on people who are now insured who would lose it.
What does the ruling say about Obamacare?
MD: If the Supreme Court had ruled against the government and said that the subsidies could not be available in the 34 states that have federally-run exchanges, it might not have been the death of Obamacare, but it certainly would have put it on life support. So this decision is really critical in helping root and solidify the Affordable Care Act. And the more it gets rooted in each of the states, the harder it’s going to be to repeal.
IW: So this actually was a 6-3 decision, not a 5-4 decision. And it does seem to me the fact that both Justice Roberts and Justice Kennedy — who were the two that one might have imagined might have been on the other side of this issue — came down on the side of upholding these subsidies is a bit of a statement.
What if the ruling had gone the other way?
MD:Think about Texas. Now, in Texas, there are about 1.1 million people who are enrolled in that exchange, that marketplace. Well, 90% of them — over 900,000 people — are receiving those subsidies, and they could have lost their insurance.
And it’s not only important that people lose their insurance, which is the most critical thing, but hospitals would see many, many more uninsured patients. So even people adamantly opposed — I think that even Republican governors who are opposed to this are secretly saying, “Oh my gosh; thank goodness.” This would have caused them a tremendous, tremendous burden, because they would have seen more uninsured.
IW: Had it gone the other way, there would not only have been a whole set of immediate short-term problems that relate to the states that have federal exchanges, but you begin to develop momentum to repeal the whole thing, or you start to develop momentum for opponents of health care reform to be emboldened and to challenge more things. And so there’s this whole sense of momentum behind health care reform, which I think would be seriously impaired.
What does this mean for the future?
MD: Repeal of Obamacare is almost off the table. This is the number one domestic policy legacy issue for the President, and it just got saved. Millions more people are going to have health insurance, and the ACA is going to be something that gets even stronger because of this. I bet we see some of the states who are not participating participate by expanding their Medicaid, by looking to the federal government to see if they can cover more people in creative ways.
IW: Repeal still could happen. But the point is it becomes much, much harder. You have two major Supreme Court decisions in support of the constitutionality of proceeding in this direction.
I think the big picture is that there’s a lot to do to continue to implement, and implement effectively, the ACA. This is a marathon, not a sprint. It’s a long process. And what the ruling means is that people can keep focused on doing that implementation work rather than rethinking it altogether.