MONEY Health Care

5 Challenges Facing Medicaid at 50

babies in hospital nursery
Corbis

The federal-state health care program covers nearly half of all births, one-third of children across the country and two-thirds of people in nursing homes.

A “sleeper” provision when Congress created Medicare in 1965 to cover health care for seniors, Medicaid now provides coverage to nearly 1 in 4 Americans, at an annual cost of more than $500 billion. Today, it is the workhorse of the U.S. health system, covering nearly half of all births, one-third of children and two-thirds of people in nursing homes.

Enrollment has soared to more than 70 million people since 2014 when the Affordable Care Act began providing billions to states that chose to expand eligibility to low-income adults under age 65. Previously, the program mainly covered children, pregnant women and the disabled.

Unlike Medicare, which is mostly funded by the federal government (with beneficiaries paying some costs), Medicaid is a state-federal hybrid. States share in the cost, and within broad federal parameters, have flexibility to set benefits and eligibility rules.

Though it provides a vital safety net, Medicaid faces five big challenges to provide good care and control costs into the future:

  1. Controlling costs — Medicaid is one of the largest items in state budgets, although its beneficiaries lack political clout. Expenses typically soar during economic downturns as enrollment increases when people lose jobs and their health benefits. That puts states in a quandary because they struggle to keep up with higher costs as their tax revenues decline. Medicaid enrollment and costs grew markedly during the last recession and enrollment shot up further since 2014 as a result of the 2010 health law (although the federal government pays the full cost of newly eligible enrollees through 2016). States typically try to control costs by cutting payment rates to doctors and hospitals or reducing benefits—both of which can have negative effects on enrollees by making it harder to get care.
  1. Getting states to expand income eligibility under Obamacare — The Supreme Court’s 2012 ruling that states could decide whether to participate in the health law’s Medicaid expansion impaired Democrats’ efforts to expand eligibility nationwide. Twenty states, mostly in the South and interior West, have refused to participate, citing concerns about the program’s effectiveness and cost. As a result, more than 4 million people have been left without health insurance because they don’t make enough to qualify for federal subsidies to buy private coverage on the health law’s exchanges, even though they are ineligible for state Medicaid programs. Texas and Florida are the two largest states that declined to expand the program. President Barack Obama has accused state Republican leaders of playing politics, but few GOP leaders have budged.
  1. Better oversight of managed care – More than half of Medicaid enrollees now get care through private managed care companies, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation). While the insurers tout their ability to offer budget predictability, questions remain about how well the companies improve quality and control costs. In managed care, health plans are paid a set monthly rate to cover each enrollee’s medical needs. The Obama administration has recently proposed rules that would limit how much these plans may spend on administrative costs and set standards to ensure enrollees have adequate access to hospitals and doctors – similar to those for private plans. A recent report by the inspector general of the Department of Health and Human Services found widespread inaccuracies in Medicaid managed care plans’ provider directories. Half of the doctors listed in the directories were unavailable because providers were not at that location, were not in the plan’s network or were no longer taking new patients.
  1. Ensuring access to doctors and dentists — Studies show people enrolled in Medicaid can get primary and preventive care as easily as those with private coverage, but have a harder time finding specialists and dentists who are willing to treat them. Nationally, the rate of doctors willing to see new Medicaid patients ranges widely, mostly because the payment rates vary significantly by state. A recent poll from the Kaiser Family Foundation found that low-income adults covered by Medicaid are somewhat more likely than those with other types of insurance to report access issues in the past 12 months. In a 2012 federal study, just 40 percent of New Jersey doctors accepted new Medicaid patients compared to 99 percent in Wyoming. While the federal government requires states to offer dental coverage for children, adult coverage is optional. Even when states offer adults coverage, patients often struggle to find dentists willing to see them because of low payment rates. In many places, community health centers have helped to meet the growing need for dental care, but patients can face long waits.
  1. Meeting growing demand for long term care–While Medicaid is often typecast as helping poor, inner-city families, it’s also the only safety net for millions of middle-class people who need long-term care at home or in nursing homes. More than 60 percent of nursing home residents rely on Medicaid for assistance. With the aging of the population accelerating in the next two decades, the demand for long-term care is expected to soar. While states have made progress shifting enrollees from more costly nursing homes to long-term care services at home and in community settings, more needs to be done.

Kaiser Health News (KHN) is a nonprofit national health policy news service.

TIME Healthcare

Birth-Control Costs Nearly Halved After Obamacare, Study Finds

TIME.com stock photos Birth Control Pills
Elizabeth Renstrom for TIME

"Spending on the pill could be cut by $1.5 billion annually"

Average out-of-pocket spending on birth control pills and intrauterine devices (IUDs) have dropped significantly since the Affordable Care Act took effect, a new study finds.

The study, published on Tuesday in Health Affairs by University of Pennsylvania researchers, compared contraceptive prescription claims from a large national insurer between the first six months of 2012, or before the “Obamacare” mandate took effect, and the first six months of 2013, or after Obamacare took effect. Comparing the two time periods, researchers found that consumers’ average out-of-pocket spending for birth control pills fell from $32.74 to $20.37, and, for IUDs, from $262.38 to $84.30.

Under the mandate, private health insurance plans are required to cover prescription contraceptives at no cost, though many women still faced costs due to insurers’ failure to comply, among other reasons.

“We estimate that the ACA is saving the average pill user $255 per year, and the average woman receiving an IUD is saving $248,” said lead author Nora V. Becker in a statement. “Spread over an estimated 6.88 million privately insured oral contraceptive users in the United States, consumer annual contribution to spending on the pill could be reduced by almost $1.5 billion annually.”

Though the report notes that it cannot definitively attribute the cost declines to Obamacare, the results are consistent with those of smaller studies that have also found sharp falls in out-of-pocket payments for contraception prescribed to privately insured women.

TIME White House

President Obama Sang the Davy Crockett Theme Song at an Event

"Is your name really Davy Crockett? That's a cool name"

When a man named James Davy Crockett asked the President a question at a town hall on Wednesday, President Obama had some questions of his own—and also, the urge to sing.

“Is your name really Davy Crockett? That’s a cool name,” Obama said. “But you don’t have that beaver cap?”

“I’ve got one at the house,” Crockett replied. (The frontiersman Crockett was actually known for a coonskin cap.)

Obama then recalled the Davy Crockett show that aired in the 1950s. “”Ya’ll remember that TV Show?” he asked the giggling crowd at Taylor Stratton Elementary School in Madison, Tenn. He then briefly broke into the show’s theme song.

The President’s exchange with Crockett began much more seriously—Crockett told the President he had unsuccessfully tried to get Social Security benefits, but had been turned down four times. Crockett’s story has been highlighted in the past, with an April Tennesseean article detailing his struggles with his health and gaining insurance. During Wednesday’s event, Obama promised to reach out to the Social Security Administration to get Crockett’s application expedited.

Obama took questions for about 50 minutes from a friendly crowd at the elementary school. He said his work on health care was not yet finished and thanked local leaders for their work in getting people in their states insured. The event followed the recent Supreme Court decision that kept the Affordable Care Act in place.

Watch a clip of Obama’s exchange with Crockett:

 

 

 

TIME White House

Obama’s Approval Rating Cracks 50%

President Obama Joins Mourners At Funeral Of Rev. Clementa Pinckney
Joe Raedle—Getty Images President Barack Obama delivers the eulogy for South Carolina state senator and Rev. Clementa Pinckney during Pinckney's funeral service on June 26, 2015 in Charleston, S.C.

After he sang 'Amazing Grace' on television and had a big week in the Supreme Court

President Barack Obama’s approval rating cracked 50% following a week of dramatic news events, marking the highest ratings for his presidency since 2013.

A CNN/ORC poll found that 50% of Americans approve of Obama’s handling of the presidency, after a week that included Supreme Court decisions on gay marriage and the Affordable Care Act, as well as several statements on race and an emotional eulogy for Rev. Clementa Pinckney, who was killed in the Charleston shooting. Obama rounded out the week by singing “Amazing Grace” on national television at Rev. Pinckney’s funeral Friday.

The poll shows a significant jump since Obama’s 45% approval rating in May, and a dip in his disapproval rating, to 47%. This is the first time his approval rating has hit 50% since May 2013, and the second time his disapproval rating has fallen below 50% in that stretch of time.

The breakdown on specific issues is also going Obama’s way. 52% said they approve of how Obama is handling the economy, which is the first time that particular metric has exceeded 50% in six years of CNN/ORC polling. 55% said they approve of how Obama is handling race relations, up from 50% in May.

Yet there are still persistent challenges for Obama, especially on race. 74% of Americans say racial discrimination against black people is a serious problem in America, up from 47% five years ago– among African-American respondents, that number has jumped from 42% to 80%. And 42% of Americans think that race relations have gotten worse under Obama, compared to 20% who think they’ve gotten better.

[CNN]

TIME Uber

Why the Obamacare Decision Is Great for Uber

Berlin's Taxis As German Court Considers Uber Technologies Inc. Ban
Bloomberg—Bloomberg via Getty Images A passenger holds a HTC Corp. smartphone displaying the Uber Technologies Inc. car service application (app) as they sit in a taxi in this arranged photograph in Berlin, Germany, on Monday, Nov. 24, 2014.

The gig economy should be celebrating this week

Uber may have publicly praised Supreme Court’s Friday decision clearing the way for nationwide same-sex marriage, but a decision that came a day earlier promises a bigger impact on the ride-hailing company.

The Supreme Court on Thursday issued a decision preserving federal tax credits tied to the Affordable Care Act, also known as Obamacare. The ACA is an essential ingredient in the success of the so-called “gig economy,” wherein workers serve as independent contractors on a flexible schedule for on-demand service companies like Uber, Postmates, Instacart and more.

Because Uber and many companies like it consider their workers independent contractors instead of employees, they’re not required to provide those workers with health insurance, as the ACA only mandates that employers extend coverage to full-time employees. That loophole saves the companies a tremendous amount of money. Obamacare’s subsidies for individual insurance buyers, meanwhile, make it easier for Uber drivers and similar workers to get affordable coverage, making the work more attractive.

Uber CEO Travis Kalanick reportedly said at a November dinner that Obamacare is “huge” for his company because it frees up more workers to come drive cars for Uber when they might otherwise be tethered to a job that offers health benefits. “The democratization of those types of benefits allow people to have more flexible ways to make a living,” Kalanick said at the dinner. “They don’t have to be working for ‘the man.'” (An Uber spokeswoman confirmed Kalanick’s comments, but declined to elaborate further.)

Indeed, when Uber recently surveyed its drivers about whether they would prefer a “9-to-5 job with some benefits and a set salary” or one where they could make their own schedule, 73% said they would forgo the benefits package in favor of freedom, according to a report the company released in January. And Uber is making efforts to help its drivers get insured, announcing late last year a partnership with Stride Health to guide workers in choosing a plan on the government insurance exchanges.

It’s unclear, however, how much Uber is actually spending, if anything, on this ancillary benefit: Stride’s services are already available for free to anyone. A spokeswoman for Uber says drivers who use Stride through Uber’s “customized” app would “save time” because their personal information would already be “pre-populated” into tool.

Still, how much longer Uber might capitalize on a combination of Obamacare and employment status rules remains up in the air. A California labor board recently found that a single Uber driver was more accurately characterized as an employee, not an independent contractor. While that decision is non-binding, it has called into question Uber’s policies regarding health insurance and other benefits. On-demand grocery service Instacart, perhaps seeing the writing on the wall, recently announced that it is experimenting with turning some of its workers into part-time employees in what could be the first step in a broader trend across gig economy companies.

For now, however, Uber is safe to celebrate. Had the Court gone the other way Thursday, it may have found its business model in serious jeopardy.

This article originally appeared on Fortune.com.

MONEY Health Care

Obamacare Still Has 5 Key Hurdles to Clear

150626_FF_ObamacareHurdles
Peter Dazeley—Getty Images

Despite the Supreme Court ruling upholding it, the Affordable Care Act still has a rocky road ahead.

In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges — including one resolved Thursday — and dozens of repeal efforts in Congress. But its long-term future still isn’t ensured. Here are five of the biggest hurdles remaining:Spacer

1. Medicaid Expansion. About 4 million more Americans would gain coverage if all states expand the state-federal Medicaid programs to cover people with incomes at or slightly above the poverty line. Twenty-one states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington’s long-term commitment to pay for most of the costs.

2. Anemic Enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven’t purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance. Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven’t figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5% of family income—whichever is larger.Spacer

3. Market Stability. Nationally, premiums haven’t gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they’re not, expect increases.Spacer

4. Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The “Cadillac tax,” created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes’ cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.

5. Political Resistance. Thursday’s ruling did little to diminish the GOP’s zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. Alawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.

Kaiser Health News writers Julie Appleby, Mary Agnes Carey, Phil Galewitz and Jordan Rau contributed to this report.

Kaiser Health News (KHN) is a nonprofit national health policy news service.

TIME Supreme Court

The Two Harshest Words Antonin Scalia Used Against Obamacare

U.S. Supreme Court Associate Justice Antonin Scalia addresses the The Legal Services Corporation's 40th anniversary conference luncheon September 15, 2014 in Washington, DC.
Chip Somodevilla—Getty Images U.S. Supreme Court Associate Justice Antonin Scalia addresses the The Legal Services Corporation's 40th anniversary conference luncheon September 15, 2014 in Washington, DC.

"I dissent."

Supreme Court Justice Antonin Scalia is known for his colorful language, using phrases like “argle-bargle” and “jiggery-pokery” in his dissents.

But the two harshest words he uses to signal his dissatisfaction with the court’s majority are actually pretty plain: “I dissent.”

Within the cloistered world of the nation’s highest court, it’s the little things that get noticed. Among them is the phrase that a Justice on the losing side of a case chooses to end their dissent with.

On the more polite end, there are a couple variations: “I respectfully dissent.” “With respect, I dissent.” “We respectfully dissent.” There’s a more neutral option, simply ending the piece without a sign-off or ending by noting “I would affirm/reverse the decision of the lower court.”

Scalia usually chooses to simply end his decision without a sign-off, but in a select few cases he has gone further and added “I dissent” just to underline the point. That’s how he ended his dissent Thursday from the 6-3 majority opinion in King v. Burwell that allowed subsidies on state-based insurance marketplaces set up through the Affordable Care Act to continue.

The court’s two decisions on Obamacare “will publish forever the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takes to uphold and assist its favorites,” he wrote. “I dissent.”

Harvard law professor Mark Tushnet, author of a book on Supreme Court dissents called I Dissent, said that’s no accident.

“I don’t know of any systematic studies, but it’s clear to me that the Justices know the difference between the two formulations and make deliberate choices about which to use,” he told TIME in an email.

The cases in which Scalia chooses to end with “I dissent” are interesting.

In 2003, he dissented from the 6-3 majority in Lawrence v. Texas striking down anti-sodomy laws.

“The matters appropriate for this Court’s resolution are only three: Texas’s prohibition of sodomy neither infringes a ‘fundamental right’ (which the Court does not dispute), nor is unsupported by a rational relation to what the Constitution considers a legitimate state interest, nor denies the equal protection of the laws,” he wrote. “I dissent.”

In 2011, he dissented in part from a 5-3 decision in Arizona v. United States that upheld a lower court ruling overturning an Arizona law that denied bail to illegal immigrants charged with some felonies.

“If securing its territory in this fashion is not within the power of Arizona, we should cease referring to it as a sovereign State,” Scalia wrote. “I dissent.”

And in 2012, he used the phrase in a dissent from a 5-4 decision in United States v. Windsor that overturned part of the Defense of Marriage Act which barred federal recognition of same-sex marriages.

“The Court has cheated both sides, robbing the winners of an honest victory, and the losers of the peace that comes from a fair defeat. We owed both of them better,” he wrote. “I dissent.”

Scalia’s liberal colleague, Justice Ruth Bader Ginsburg, recently said in an interview at the American Constitution Society that she stopped writing simply “I dissent” after liberals overreacted to her use of it in the 2000 Bush v. Gore case, even putting it on T-shirts. She now simply notes that she would uphold or overturn the lower court decision.

Still, Ginsburg said the “respectfully” line seems like a silly fiction.

“I think of my colleagues who have just criticized the court’s opinion as being ‘profoundly misguided’ — that’s one from (former Justice) John Paul Stevens — or from Scalia ‘this opinion is not to be taken seriously’ and then after saying that, then you end it (with ‘I respectfully dissent’ when) you’ve show no respect at all,” she said.

TIME society

Obamacare Victory Shows Failure of Scalia’s Conservative Revolution

Justice Antonin Scalia at the "Magna Carta: Muse and Mentor" evening program at the Library of Congress on Nov. 6, 2014.
Kevin Wolf—AP Justice Antonin Scalia at the "Magna Carta: Muse and Mentor" evening program at the Library of Congress on Nov. 6, 2014.

This is clearly not the Scalia Court

By upholding a key provision of the Affordable Care Act (ACA) in King v Burwell, a majority of the U.S. Supreme Court demonstrated that while the conservative revolution led by Justice Antonin Scalia may have had a strong impact on the court (and on the nation), it has not succeeded in winning over Justice Anthony Kennedy or Chief Justice John Roberts. Thus, while Justice Scalia has won many battles, he has not won the war. And in today’s King v Burwell decision he lost a major battle.

Justice Scalia has fought tirelessly both to limit the court’s focus in interpreting statutes (in other words, to look only at the letter of the law and not at the broader purpose of the legislation) and to limit the power of the national government.

King v Burwell seemed tailor-made to vindicate both goals.

The basic question in King v Burwell was whether the phrase an “exchange established by the state” included health care exchanges established by the federal government in states that refused to create their own. The plaintiffs in King v Burwell argued that “established by the state” means that health insurance subsidies could not be offered in states that had chosen to use the federal health insurance market instead of their own. This is, indeed, a very strict interpretation.

For Justice Scalia, the answer was easy: “established by the state” could not possibly mean “established by the state or the federal government.” Had Justice Scalia’s textualism prevailed, the decision would have gutted the ACA. Six million people in the 34 states where the federal government runs the insurance marketplace could have lost subsidies, and premiums could have skyrocketed.

But that didn’t happen. Instead, Chief Justice Roberts wrote an otherwise unremarkable opinion that invoked traditional principles of statutory interpretation and examined the meaning of the phrase “established by the state” in context.

The chief justice looked beyond the plain language of the clause at issue. He insisted that a court should interpret the language of the law in light of the overall legislative purpose. As the chief justice wrote:

Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.

And a contrary interpretation would have defeated the central purpose of the statute. In this approach, the court acts as Congress’s partner, not its censor.

In his dissent, Justice Scalia was clearly furious that Chief Justice Roberts refused to endorse his revolutionary approach to statutory interpretation.

From Justice Scalia’s perspective, Chief Justice Roberts’ heresy was magnified by the fact that the chief justice cast the deciding vote to validate the Affordable Care Act in NFIB v Sebelius in 2012, in which the legality of the individual mandate was upheld.

When Justice Scalia gets mad, he does not hold back. He has often adopted fairly sharp language in his dissents, but even by that standard, his dissent in King v Burwell is extraordinary in tone:

Normal rules of interpretation seem always to yield to the overriding principle of the present court: the Affordable Care Act must be saved.

His vituperation reaches a crescendo in the conclusion where he snipes, “We should start calling this law SCOTUScare.”

One can debate the appropriate moniker for the ACA, and one can debate whether we should call this the Roberts Court or the Kennedy Court, but what is beyond debate is that this is not the Scalia Court.

This article originally appeared on The ConversationThe Conversation

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

MONEY Health Care

What is Obamacare?

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Here's how President Obama's health insurance reform law actually works

Today, there’s been a lot of talk about the Supreme Court’s latest ruling on the Affordable Care Act, better known as Obamacare. But while the law signed by President Obama in 2010 made huge changes to the health insurance system, most people under 65 still get their coverage the way they always did: from their employer. Unless you bought a health insurance plan on a government-run marketplace, you might not be familiar with how the ACA provides coverage. Here are answers to some common questions:

How does the law help people get insurance?

The law set up insurance “exchanges” that offer consumers and small businesses a choice of standardized and heavily regulated health plans. For the most part, this marketplaces serve people who aren’t offered insurance by a large employer.

And how is that different from the way people bought their own insurance before?

On the exchanges, insurers are not able to turn anyone down because of a pre-existing condition; from pregnancy to heart disease, they’re all covered. The law also restricts or blocks annual and lifetime limits on what insurers, including in employer plans, will pay.

Rates aren’t tied to your health, although smokers may have to pay up to 50% more. The oldest people in a plan will pay no more than three times the rate paid by the youngest. In short, policies you buy yourself will be a lot more like the group plans you get at work.

What does coverage cost?

The insurance on the exchanges isn’t free—a family of four could well face annual premiums of $10,000 a year. But many of those using the exchanges will also receive federal subsidies—technically, tax credits—to help them buy. Those subsidies reach deep into the middle class: For families earning up to four times the poverty line—about $95,000 for a couple with two kids—the tax credits will be set so that they pay no more than about 9.5% of their income for a fairly basic health plan. (That cap is designed to rise gradually should premiums grow faster than incomes.)

People with lower incomes pay even smaller percentages. Some pay almost nothing.

The law was also meant to allows millions of the near poor to join Medicaid through the exchanges, although a Supreme Court decision left it up to individual states whether to participate in the expansion. Currently, 21 states are opting out.

What kind of coverage can I get?

All the plans must provide at least a standard menu of essential benefits. They come in four basic types: bronze, silver, gold, and platinum.

Although plans can compete by mixing different premiums, deductibles, and co-pays, you’ll know the average level of out-of-pocket costs you can expect in each type. For example, the silver plans ask you to pay about 30% of your costs out of pocket. (Subsidies are based on the cost of the silver plans.) The more expensive platinum plans, which would be most similar to a large employer’s coverage, would have out-of-pocket costs of just 10%.

How is all this paid for?

In a number of ways, but the most direct one is that high earners got a payroll tax hike. Starting in 2013, couples have paid additional taxes on earnings above $250,000 ($200,000, if you’re single)—0.9% on earned income and 3.8% on investment income.

Why are some people fined for not buying coverage?

By 2016 you’ll be dunned $695 a year or 2.5% of your income, whichever is higher, if you don’t have health insurance. However, there’s an exemption if premiums top 8% of your income. Insurers fought for this provision. Even with subsidies, some people may decide that coverage is too expensive. They’ll tend to be healthier than average—that’s why they’d be willing to take the risk. But that poses a problem in a system where insurers have to take all comers. If healthy people drop out, the pool of people paying in will typically be sicker and more expensive to treat. That causes premiums to rise, which causes more healthy people to drop out, which means higher premiums, and so on. To prevent this “death spiral,” the law pushes people to buy.

Adapted from “The Truth About Health Care Reform,” which appeared in the May 2010 issue of MONEY.

TIME Supreme Court

Obama Says More Work to Be Done on Expanding Health Insurance

“The Affordable Care Act is here to stay."

President Obama took a brief victory lap over the Affordable Care Act before saying it was time to get back to work.

Speaking from the Rose Garden a little over an hour after the Supreme Court ruled in favor of keeping in place subsidies that make insurance affordable, the President declared victory for his signature health law.

“The Affordable Care Act is here to stay,” Obama said. “Today is a victory for hard working Americans all across this country whose lives will continue to become more secure in a changing economy because of this law.”

After five years, over 50 Congressional votes for its repeal and two Supreme Court decisions, Obama said the law is now “woven into the fabric of America” and won’t be unraveled.

Under the Affordable Care Act, over 16 million previously uninsured people have gained coverage. The uninsured rate has dropped dramatically and millions have access to subsidies that makes their new insurance plans more affordable.

‘This is not an abstract thing any more. This is not a set of political talking points. This is reality,” Obama said.

Still, the political debate over the Affordable Care Act has loomed large of the last three election cycles, and there are signs it may continue in 2016. Republican lawmakers and presidential contenders have vowed to make replacing the law their top priority once Obama leaves office. A number of Republican states have yet to expand Medicaid coverage under the law.

But in the Rose Garden, Obama vowed to “keep working” to get more Americans covered.

“With this case behind us, let’s be clear, we’ve got work to do to make health care in America even better,” he said.

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