How many Americans are anti-Obamacare hard-liners willing to harm in their war against the landmark health reform law? The answer — millions — became shamefully clear after a conflicting set of federal appellate rulings this week cast an unnecessary cloud over the Affordable Care Act's future.
About 4.6 million people who obtained private health insurance this year through Healthcare.gov, the federal insurance marketplace serving 36 states, received tax-credit subsidies to lower the cost of their monthly premiums. That number is expected to rise to 7.3 million over the next two years, according to a recent analysis by the Robert Wood Johnson Foundation and the Urban Institute.
But the latest court challenge concocted by Obamacare opponents takes aim at the legality of the subsidies for those living in states relying on Healthcare.gov instead of a customized, state-built exchange — such as Minnesota's MNsure. If the dubious argument that Congress only intended subsidies to be distributed through state exchanges eventually finds favor with the U.S. Supreme Court — Tuesday's contradictory rulings set the stage for this review — millions of Americans now able to get care without fear of financial catastrophe could once again find themselves without coverage.
Many of those now qualifying for subsidies through the federal exchange would take a double hit, a fact often missed in news coverage. They're also currently eligible for so-called "cost-sharing" assistance to defray expenses such as copays. That assistance likely would "terminate,'' according to a legal briefing distributed this week to state health policy experts.
Those tempted to cheer on the latest legal challenge to the ACA ought to consider these numbers: Each of the nearly 5 million who received the subsidies this year — those who qualify must meet income guidelines — is someone who potentially would not be able to fill a prescription or take their child to the doctor if the tax credits simply disappear.
Now add in the estimated 8 million even poorer Americans who would have qualified for Medicaid but remain uninsured because they live in mostly southern states not expanding this program in order to strike a blow against Obamacare. The tally of Americans whose medical care is in jeopardy for purely political reasons is already an outrage. The latest legal challenge could send that number soaring.
At what point does the incredible cost of this political gamesmanship start sinking in with the law's mostly Republican opponents? Thinking that this confers some political advantage is also deluded. "There will be utter chaos throughout the country as people getting insurance subsidies have them yanked away. Think of the controversy when people weren't able to renew their policies last year. Multiply it by 20 to 30 times to get at what this would entail,'' said Henry Aaron, a Brookings Institution health policy expert.
What's even more frustrating is that there aren't broader legal principles at stake, as there were with a previous court challenge to the health law's mandate to buy health insurance. In 2012, the U.S. Supreme Court upheld the mandate by treating it as a tax but gave states unexpected latitude to decline to expand Medicaid, one of the key ways the ACA expands access to coverage. The tax credits used to buy private insurance provide another critical way to accomplish this.
