MONEY Health Care

Why Obamacare Is Making Medicare Open Enrollment More Confusing

Tangle of Stethoscopes
Comstock Images—Getty Images

The time to sign up for an individual health insurance plan overlaps with the annual window for switching your Medicare plan. Here's how seniors can navigate this tangle of health care choices.

This is enrollment season for two huge public health insurance programs: Medicare and the Affordable Care Act health insurance exchanges. For older Americans, the overlapping sign-up periods can lead to confusion and enrollment errors.

Insurers offering Medicare and ACA policies have big money at stake, and consumers are subject to a blizzard of marketing messages. Annual enrollment for Medicare prescription drug (Part D) and Advantage (Part C) plans began Oct. 15 and runs until Dec. 7; shopping for healthcare policies in the marketplace exchanges created under the ACA began Nov. 15 and ends Feb. 15.

Consumer assistance groups report that some Medicare enrollees mistakenly think they must also enroll in the ACA exchanges. And for people with ACA plans who are turning 65, the transition to Medicare can be tricky. Here are some common questions about enrollment overlap, and answers aimed at helping older Americans keep things straight.

Q: What should I do about the ACA marketplaces if I’m already on Medicare?

Nothing. The policies sold on the exchanges are for Americans who don’t have coverage through an employer. And it is illegal for someone to sell you an exchange plan if the provider knows you are covered by Medicare. You can’t buy a Medicare Advantage, Medigap or Part D drug plan through the ACA marketplaces; to enroll in these plans, visit the federal government’s Medicare Plan Finder website.

Q: I bought health insurance this year on my state’s exchange, but I’m turning 65 in December. Do I need to shift to Medicare then?

It’s critical that you move to Medicare as soon as you are eligible. The enrollment window starts three months before your 65th birthday and ends three months afterward.

Failure to enroll will saddle you with expensive premium penalties. Monthly Part B premiums jump 10% for each 12-month period that you could have had coverage but didn’t—for life. That can add up: A senior who fails to enroll for five years ultimately would face a 50% Part B penalty—10% for each year. Penalties also are applied for late enrollment in Part D, under a different formula.

Q: When I shift into Medicare, can I just stick with the company that insures me in the ACA exchange?

You probably could do that; many of the nation’s biggest health insurers operate in both Medicare and the ACA exchanges. But brand loyalty isn’t advised here. Even if you’ve been satisfied with your provider, that company’s Medicare prescription drug plan may not offer the same coverage you had in the exchange. And the Medicare Advantage plan may not include the same network of providers or level of benefits.

Treat Medicare sign-up as a new shopping exercise. For starters, think about whether you want traditional fee-for-service Medicare or Advantage, a managed care alternative. Traditional Medicare allows you to see any health provider that participates in Medicare, but you’ll probably want to add a standalone prescription drug plan and a Medigap supplemental policy. With Advantage, you’ll be limited to in-network providers, but most plans have built-in prescription drug coverage and cap out-of-pocket spending.

Q: I qualified for tax subsidies in the ACA exchanges. Will those continue when I go into Medicare?

No. The ACA subsidies offset premium costs for households in a wide band of income, from 100% to 400% of the federal poverty level. This year that worked out to an annual income of between $11,490 and $45,960 for an individual, and $23,550 to $94,320 for a family of four.

Medicare enrollees can get assistance with premiums if they meet certain income and asset tests through the Medicare Savings Program. Another program, called Extra Help, can offset most or all prescription drug costs. The Medicare Rights Center’s website has a summary of these programs.

TIME Health Care

Obamacare Support Drops to 37%, Survey Says

U.S. President Barack Obama listens to a question at a news conference at the end of the G20 summit in Brisbane
U.S. President Barack Obama listens to a question at a news conference at the end of the G20 summit in Brisbane, Australia on Nov. 16, 2014. Jason Reed—Reuters

Even as 100,000 people spent the weekend signing up for insurance

Americans’ approval of the Affordable Care Act has fallen to a new low, according to a new poll, even as 100,000 people spent the weekend signing up for health insurance under the program.

A Gallup survey conducted Nov. 6-9, in the days after Republicans won control of Congress in the midterm elections, finds only 37% of Americans approve of President Barack Obama’s signature health care law, for which the second open-enrollment period began on Nov. 15. Lower approval was noted among independents and non-whites, at 33% and 56%, respectively.

Support for the law has been consistently low since November 2013, around the time the first open-enrollment period began. In January, support reached its previous low of 38%. Gallup notes that “approval of the law has remained low throughout the year even as it has had obvious success in reducing the uninsured rate.”

Many Republicans have called for an all-out repeal of the law, which is unlikely, though Obama could still agree to modify parts of it.

MONEY Health Care

What You Need to Know About This Year’s Obamacare Kick-Off

Obamacare Take 2 film clapper
Sarina Finkelstein (photo illustration)—Getty Images (clapper)

It's Year Two for health reform, as the online insurance exchanges open on Saturday. Here’s what to pay attention to if you're in the market for a plan.

Starting Saturday, consumers who buy their own health insurance can finally sign up for a 2015 plan. Healthcare.gov, the troubled online insurance market created by the Affordable Care Act—a.k.a. Obamacare—will begin accepting enrollees, as will the 14 state-run insurance exchanges.

This year the government opened the federal site for window shopping in advance, so you’ve been able to get a sneak peek at what’s available in your area before the formal sign-up process kicks off this weekend. Although experts can’t promise that open enrollment will run smoothly this go-around, they do think the process will face fewer problems.

If you bought insurance last year, you may figure that you don’t need to do anything in year two. Or if you went without last year, perhaps you plan to do the same. Not so fast. Read this before you make any health-care shopping decisions.

Skipping Insurance Will Cost You More

If you decided to go without health insurance in 2014, you’ll likely get hit with a penalty when you file your income taxes this April. It’ll be the greater of $95 for an adult ($285 per family) or 1% of family income.

But going without insurance in 2015 will cost you even more. For the 2015 plan year you’ll owe the greater of $325 for an adult ($975 per family) or 2% of family income, which you’ll pay with your taxes in spring 2016.

You may qualify for an exemption if the lowest-cost plan in your area would cost you more than 8% of your income, or if you went without insurance for fewer than three months.

Even If You Enrolled Last Year, You Should Shop Around Again

By now you should have received a notice from your current health plan explaining that your coverage will end December 31. You’ll also be told whether the insurer will offer that same plan in 2015 and, if so, what it will cost and how it will change, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

If you signed up for coverage last year, or even just a month or two ago, you may think you’re all set. Why go through what was likely a taxing experience, given the technical problems the exchanges had last year? Here’s why.

First, there’s a good chance you’ll have different plans to choose from this year. Some insurers will exit the marketplaces, but many others have joined. In 35 states, the number of insurance companies offering coverage on a state exchange is increasing, according to the Kaiser Family Foundation; only two states, California and Oregon, will see a slight decline. New Hampshire, which had one insurer participate in its exchange in 2014, is adding four new insurers for 2015. In Ohio, you’ll find five new insurers, and four in Pennsylvania.

Premiums are also changing. An early analysis of monthly plan costs across 15 cities found that the premium for the second-lowest-cost silver plan, before taking any income-based tax credits into account, is decreasing by an average of 0.8%, according to the Kaiser Family Foundation. However, that’s not true everywhere. The premium for that silver plan will jump 8.7% in Nashville, for example, 6.6% in Burlington, Vt., and 6.0% in Portland, Ore. The cost will drop 15.6% in Denver and 11.4% in Providence.

You’ll want to get to know your new choices and reassess your options. “It’s a good idea for consumers to check in, see what is being offered and its cost, and make an active decision to keep their plan or make a change,” says Pollitz.

Your Subsidy Could Change (Even If Your Income Didn’t)

What’s more, if you qualified for a tax credit last year, which about 85% of exchange enrollees did, update your income information and financial assistance application and see how much of a subsidy you’ll qualify for in 2015. Even if your income hasn’t changed, the subsidy you’re eligible for may go up or down. That’s because it is based off the price of the second-lowest silver plan in your area, which could have changed.

You can use this newly updated calculator from the Kaiser Family Foundation to estimate your subsidy.

You’re Not Stuck With Healthcare.gov

While the federally run site garners most of the attention, it isn’t the only place you can sign up for a plan.

If you expect to qualify for a premium subsidy (available if your income falls between 100 and 400% of the federal poverty level), your options are somewhat limited. You’ll either have to shop on the exchange or a health comparison site that’s authorized in your state to sign you up even if you qualify for a subsidy, such as ehealthinsurance.com and gohealth.com.

If you aren’t going to qualify for a subsidy, you can buy insurance anywhere, including directly from a private insurer. Just keep in mind that if you look at only a single insurer’s plans, you may miss less expensive or more appropriate options from competitors.

For the first time this year many Walmart stores have kiosks manned with insurance agents to answer questions about your plan options. They won’t be able to sign you up in the store, however. You’ll need to call or go online to directhealth.com to enroll.

Given the complexity of your options and the sign-up process, it’s understandable if you’d like telephone or in-person help. You can find local navigators or other resources in your area, such as nonprofits and consumer advocacy groups, at localhelp.healthcare.gov.

Drag Your Feet and You Could Be Auto-Enrolled

Don’t wait until the last minute to shop, warns Pollitz. In most states consumers who have not actively chosen a new plan by December 15 will be automatically re-enrolled in their current plan, or switched to a similar one if that plan is no longer available. While you can still swap coverage even after you’ve been re-enrolled, try to avoid that headache.

In a few states, such as Massachusetts and Oregon, there won’t be any auto-renewal, says Pollitz, so if you want coverage next year you must actively renew. You also won’t be auto renewed if your insurer is exiting the market in your area.

You Could Be Locked Out if You Delay

Pre-Obamacare, you could buy an individual health insurance plan at any time (assuming you were in good enough health to be approved, of course). Now the annual open enrollment window, which runs from November 15 through February 15 this year, is the only time you can sign up for individual coverage for 2015 (and you can’t be turned down based on your health).

Unless you have what’s called a qualifying event during the year, such as losing job-based health coverage or moving to a different state, you will not be able to buy a plan, putting you at risk of paying a penalty.

Despite all of the media attention and outreach last year, many consumers who didn’t buy during the 2014 open enrollment period were surprised to find out later that they were locked out, says Carrie McLean, director of customer care at ehealthinsurance.com.

Others found themselves locked out until next year because they had lost insurance due to a life change (new job, divorce) and didn’t realize the window to buy coverage closed in 60 days. If they finally got around to trying to sign up months later, it was too late.

Since the new rules have kicked in, ehealthinsurance.com has recorded a spike in interest in short-term health plans. These plans, however, offer limited benefits and do not fulfill the requirement that you buy a qualified plan or pay a fine. All the more reason you need to shop now.

TIME Health Care

The Truth About Gruber-Gate

Republicans think they have found a smoking gun that exposes a nefarious plan by the Obama Administration to lie to the public in order to build support for the Affordable Care Act. This week, several videos from 2012 and 2013 have surfaced that show MIT Professor Jonathan Gruber, a former paid consultant to the Administration on health reform, calling the American people “stupid” and saying “a lack of transparency” was crucial to getting the ACA passed in 2010.

“Stupid” is not a great word to use to describe anyone, and Gruber said Tuesday that he regretted the comment. But rather than a smoking gun, Gruber-gate is actually a flash of candor in a debate that was filled with disingenuous statements from both sides. Supporters of the law did, in fact, do their best to obscure unpopular provisions—like new taxes. But Republican opponents were just as deceptive in their efforts to exaggerate the law’s potential negative effects. Neither is excusable.

The American people did not really understand the intricacies of the ACA before it passed. In April 2010, 55% of Americans said they were “confused” by the law, even after it passed and its provisions had been parsed for months in the media. Some of the confusion was due to Washington rhetoric that obscured the true details of the law and some can be blamed on a media that focused more on the politics of the bill than its policies.

It also seems unrealistic to expect average citizens to sort through a piece of legislation as large and complicated as the ACA to judge fact from fiction. Instead, the public largely relied on the opinions and information disseminated by politicians they agreed with generally.

That’s where the party-line deceptions come in. In one video, Gruber says that if the public had really understood that the law would require healthy people to pay for sick people, it wouldn’t have passed. He also says that the penalty for not having insurance is a “tax,” even though Democrats didn’t use that word to describe it because it would have made the law politically unfeasible. In another video, Gruber explains that a new ACA tax on high-cost health plans supposedly levied on insurers would actually be passed through to consumers.

None of these facts are exactly revelatory. Healthy people subsidizing sick people is how health insurance works. Whether it’s perceived as a “tax” or not, nobody wants to pay a financial penalty for not having insurance. And of course it’s true that any company—including an insurer—will try to pass overhead costs on to its customers.

The truth is there was deception on both sides of the debate that preceded passage of health care reform. Two wrongs don’t make a right—transparency is always better and more fair—but such context is necessary when judging Gruber and his remarks caught on tape. Republicans propagated talk of “death panels” and the notion that health reform would “ration” care, putting a board in charge of deciding who could live or die. The ACA does neither. The GOP also peddled the false idea that Democratic health reform was a “government takeover,” an argument that conveniently left out the fact that government dollars account for more than half of all health spending, with or without the ACA. And Republicans cast the entire discussion of the “public option,” a Medicare-like government insurance plan consumers could buy if they wanted to, as socialized medicine for all.

I’ve talked to Gruber many times over the past six years. He’s a good source because he’s smart, candid and was privy to the Democratic behind-the-scenes thinking and maneuvering that preceded passage of the Affordable Care Act. Gruber has always spoken so freely that I suspect the Obama Administration never felt completely at ease with the idea that one of its chief consultants was out there explaining everything, untethered. Comments Gruber made in 2012 about the health law’s subsidy system, which were also caught on tape and which he later described as “off the cuff,” could weaken the government’s case when it defends the law before the Supreme Court next year. (I reached Gruber to discuss this latest video controversy and he declined to comment on the record.) Gruber’s usually willing to talk and often, it seems, he’s not thinking much about the political ramifications of what he says.

In 2013, for instance, I asked Gruber if Democrats understood that the ACA would slowly and methodically erode the system under which millions of Americans get health insurance through their jobs. In pitching the ACA, Democrats had been adamant that the law would support and sustain the employer-based system, not erode it. But Gruber knew better and he told me so, likening workers being kicked off job-based health plans to people “falling off a building,” an outcome that architects of the ACA knew was likely and had planned for.

At least one Republican in Congress has called for hearings over Gruber’s newly revealed comments. Buoyed by a midterm election that gave the party a larger majority in the House and a new majority in the Senate, Republicans are hoping that Gruber-Gate might help them dismantle parts of the ACA next year.

What’s significant about Gruber-gate, though, is not that the Obama Administration was less transparent about what the ACA would do than its critics. It’s that Gruber admitted that his side participated in this unseemly dance.

MONEY Health Care

Why You May Need to Act Fast to Keep Your Health Coverage

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Obamacare open enrollment begins this Saturday and runs through February. But waiting too long to sign up for insurance could put you at risk of owing a penalty—and leave you stuck with big medical bills.

Mind the gap. When the 2015 open enrollment period begins on Nov. 15 for plans sold on the individual market, consumers should act promptly to avoid a gap in coverage.

Failing to do so could not only leave you exposed to unexpected medical bills—hello, appendicitis!—but you could also be hit with the penalty for not having health insurance that kicks in if you’re without coverage for three months or more during the year. The coverage requirement applies to most people in group and individual plans unless they qualify for a hardship or other type of exemption.

In 2015, the penalty will be the greater of $325 or 2% of household income.

The open enrollment period runs through Feb. 15, 2015. But if you bought a plan last year and need to renew your coverage, you must do so by Dec. 15 if you want it to start Jan. 1.

In general, you must buy a plan by the 15th of the month in order to have coverage that starts the first of the next month. So if you buy a plan on Dec. 16, for example, your coverage won’t start until Feb. 1.

If you don’t have insurance and you buy a plan by Feb. 15, your coverage will begin by March 1 and you’ll avoid owing the penalty since your coverage gap will be less than three months.

Last year, the marketplaces got off to a bumpy start and many people weren’t able to sign up for coverage before open enrollment ended on March 15. The federal government allowed anyone who got their application started before the deadline to avoid the penalty.

This year, President Barack Obama has vowed that the marketplace will function on time. “We’re really making sure the website works super well before the next open enrollment period. We’re double- and triple-checking it,” he told reporters last week.

There is also another way that people can be affected by the coverage gap. For people who are receiving premium tax credits but lose or drop their coverage, health plans are required to allow them a 90-day grace period to catch up with their premiums if they fall behind, as long as they’ve already paid at least one month’s premium that year. But they don’t have 90 days before the coverage gap countdown starts. If after three months someone still hasn’t paid what he owes, his coverage would be terminated retroactive to the beginning of the second month of the grace period. In that case, the penalty clock for not having coverage would start ticking after the first month of nonpayment, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

People who aren’t receiving premium tax credits on the exchange would be subject to state laws regarding grace periods for nonpayment. Typically they’d have 30 days to pay up, Solomon says.

If you lose your job-based health insurance, you’ll have 60 days after your coverage ends to sign up for new coverage. This “special enrollment opportunity,” as it’s called, would count toward a gap in coverage.

Although people are limited to a single coverage gap of less than three months annually, some may be able to sidestep the issue.

“If you have coverage on any day during a month you’re considered covered for the month,” says Solomon.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

TIME Health Care

Millions Fewer Americans Will Enroll in Obamacare Plans Than Predicted

The home page for the HealthCare.gov on March 31, 2014 in Washington, D.C.
The home page for the HealthCare.gov on March 31, 2014 in Washington, D.C. Karen Bleier—AFP/Getty Images

Through the law’s new marketplaces in 2015

Expectations for how effectively the Affordable Care Act would impact the U.S. uninsured rate were high—too high in fact. That’s according to an analysis released Monday by the Department of Health and Human Services that says millions fewer Americans will get private health insurance through the law’s new marketplaces in 2015 than was previously estimated.

The department now says it expects between 9 and 9.9 million Americans to enroll in private health plans through state and federal exchanges by next year, down from 13 million, which the nonpartisan Congressional Budget Office had predicted. The revised projection is due to deeper analysis on how long it takes for new federal programs to “ramp up,” according to HHS, which said the new estimate includes about 6 million Americans who will re-enroll in plans through the exchanges, as well as new customers who buy coverage there. Some 7 million Americans are enrolled in exchange plans today.

“The next group of people will be harder to reach,” HHS Secretary Sylvia Mathews Burwell said at a Center for American Progress event on Monday. Open enrollment through the ACA’s insurance exchanges is set to begin Nov. 15 and last until Feb. 15, 2015. Last year’s enrollment period was plagued by major technology snags, with the federal insurance marketplace HealthCare.gov and some run by states largely inoperable at the outset. The snafus embarrassed President Obama’s Administration and cast doubt on HHS’s ability to manage a large, complicated new program.

To avoid similar issues this year, Burwell said HHS and the contractors who are building and operating HealthCare.gov have been testing the system for five weeks. Burwell said tech experts are testing how many users the systems can handle at once and whether various parts of the computer programs work seamlessly together. Security testing is also part of the process, Burwell said, in addition to a simpler application for coverage that reduces the screens a new consumer must navigate from 76 screens to 16. “Things are simpler, faster and more intuitive,” she said.

Still, the secretary warned that performance perfection in the exchanges is unlikely. “We will have outages. We will have downtime,” she said.

TIME Health Care

Obamacare Site to Open Early to Avoid Repeat Rollout Disaster

Obamacare Healthcare.gov
In just a few weeks, millions of people will be heading to the federal site HealthCare.gov to shop for medical insurance when a new open-enrollment period begins. The Washington Post/Getty Images

Officials promise smoother shopping experience this time

The website for buying insurance plans under President Barack Obama’s health care law will open early ahead of the new enrollment period, officials said Sunday, as the Administration looks to avoid a repeat of HealthCare.gov’s disastrous initial rollout last year.

The website will reopen Monday to allow consumers to “window shop” health insurance market places before enrollment starts Nov. 15, said Marilyn Tavenner, the Administrator at the Centers for Medicare and Medicaid Services. The early browsing option is different from last year’s enrollment period, when consumers couldn’t see details of plans until enrollment started.

MORE: Obama’s race for the cure

“New features will give consumers a comprehensive picture of the plans in their area so they can choose the one that’s right for them,” Tavenner said in a statement.

Officials have also made the process of browsing plans easier: Last year, consumers had to answer a series of questions before even seeing plans. Now, all they have to do is enter their zip code.

MORE: Inside the team that fixed HealthCare.gov

The botched rollout of HealthCare.gov severely handicapped the opening months of implementation of Obama’s signature domestic achievement, giving fodder to Republican critics of the law. Officials eventually fixed problems with the website and final enrollment figures exceeded expectations.

MONEY Health Care

5 Things You Need to Know About Obamacare This Year

empty shopping baskets
If you buy your own health insurance, get ready to shop. Larry Washburn—Getty Images

You can start shopping for an individual health insurance plan for 2015 this Saturday. Keep these tips in mind.

The health law’s open enrollment season is just around the corner. Are you ready?

Here’s a quick checklist for people who don’t get their health insurance at work and plan to shop for coverage on the health law’s online exchanges, or marketplaces, starting Nov. 15. You can compare plans and prices at healthcare.gov or, if your state has its own exchange, shop there to find out which coverage is best for you. And you may be eligible for subsidies to help pay your premium.

Keep these five things in mind as the three-month open enrollment period begins.

1. Shop Around. Just because you’re enrolled in a policy now doesn’t means it’s the best deal for you next year. If you’re currently in the federal marketplace and don’t take any action, you’ll be re-enrolled in the same plan you’re in now. Federal officials, as well as many analysts, are urging consumers to go back to the exchanges to compare plans and prices. You might discover that you have more—or different—choices than you had a year ago.

2. Don’t Get Billed Twice. Insurers have expressed concerns that if a consumer changes plans, problems with the federal website might keep insurers from learning of the change and consumers could get billed for both plans. “It’s an issue we’re aware of and we’re working with exchange officials to make sure there’s a solution for consumers,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry trade group. Aaron Albright, a spokesman for the Centers for Medicare & Medicaid Services, said insurers will get lists of individuals who have been automatically enrolled into their current plan as well as those who chose to re-enroll. He also said that the agency is “examining options” on how to provide insurers the names of people who picked another plan during open enrollment.

Just in case, keep proof of payment to answer any billing questions and once you’ve cancelled the old policy watch your credit card statements or, if the payment was deducted directly from a bank account, watch those charges to make sure you aren’t paying for two policies. And don’t cancel your current insurance until you have confirmation from your new carrier that you’re covered.

3. Find Out If You Qualify For Financial Help. Enter your most up-to-date income information on healthcare.gov or with your state exchange to see if you are entitled to receive a tax credit toward the cost of your health insurance. Even if you are like the majority of those enrolling in marketplace plans who receive a subsidy, update your income to make sure you get the correct amount next year. This is important because if you get too much of a subsidy, you’ll have to repay it when you file your taxes the following year.

4. Know All Costs. It’s not just the monthly premium that will cost you. Understand a policy’s out-of-pocket costs, things like co-pays, co-insurance and deductibles, before you enroll. The health law allows out-of-pocket maximum caps of $6,600 for an individual policy and $13,200 for a family policy in 2015 but some of your health care expenses—including out-of-network care—might not be included in that cap.

5. Get Help If You Need It. Confused? There are several ways to get help. Work with a local insurance agent or broker. Find one of the law’s trained navigators or assistors. Or call the federal consumer assistance center at 800-318-2596 for extra help or to find out if you eligible for a subsidy. Folks there can also help you enroll in a health plan or if you qualify, Medicaid, the federal-state program for low-income people.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

TIME Health Care

U.S. Supreme Court To Hear New Challenge to Obamacare

A Supreme Court ruling against the Affordable Care Act could leave millions without insurance

The Obama Administration will have to defend the Affordable Care Act before the U.S. Supreme Court one more time. On Friday, the Justices agreed to hear a case that will determine the legality of a key element of the law: the administration’s system for distributing health insurance subsidies. The new case poses as great a threat to Obamacare as the 2012 legal challenge to the law’s requirement that nearly all Americans have health insurance.

At issue in the new case, King v. Burwell, is the ACA’s primary means for making insurance more affordable for middle-income Americans without job-based coverage. The law provides income-based subsidies to those buying health plans through the ACA’s state and federal marketplaces, known as exchanges. The new challenge argues the federal provision of subsidies goes beyond what the law authorized and is therefore an unconstitutional encroachment on Congressional control of government spending.

The problem for the Obama administration lies in ambiguous language deep in the heart of the law. The ACA says that consumers can qualify for the subsidies if they purchase insurance through an exchange “established by the state.” Many states opted not to set up their own exchanges, however, and where state exchanges don’t exist the law included a federal fall back. Residents in states without exchanges can purchase insurance through a federal exchange instead. Challengers say the law only authorized the subsidies for the state exchanges.

A July 2014 analysis by the Robert Wood Johnson Foundation found that some 7 million Americans could be eligible for subsidies through the federal exchange by 2016, meaning the elimination of the federal part of the system could significantly increase the U.S. uninsured rate. At the same time, getting rid of the federal subsidies could create a host of other consequences. For example, if subsidies for millions of people were ruled invalid by the court, but the law’s individual mandate remained in place, some Americans could suddenly face fines for being uninsured.

Lower courts have issued conflicting rulings on the latest challenge, spurring the Supreme Court to take it up. U.S. Solicitor General Donald Verrilli is a probable candidate to defend the law when the high court hears the case sometime next year, likely in March or April. He got a mixed result the first time he appeared before the Supreme Court on the subject of health reform. Justices in 2012 upheld the individual mandate, but said the federal government lacked the authority to require states to expand their Medicaid programs. The latter decision meant that millions of adult poor Americans living in states that decided not to expand Medicaid under the ACA remain uninsured despite the law.

TIME health insurance

How a Repulican Majority Could Change Obamacare

With Republicans soon to be in charge of the House and Senate, talk of repealing the Affordable Care Act (ACA) is heating up again. Here’s what you need to know about Republicans’ plans for the law and whether the GOP has a chance at changing—or repealing—it in the next two years.

 

Full Repeal

House Republicans have voted more than 50 times to repeal Obamacare. Even with its new Senate majority, the GOP lacks the 60 votes necessary to overcome a filibuster, meaning repeal legislation is unlikely ever to reach President Obama’s desk. Even if it did, he has said he would veto such a bill.

Incoming Senate Majority Leader Mitch McConnell has indicated he may try to alter the ACA through the budget reconciliation process that requires just a 51-vote majority, but full repeal isn’t possible under the special budget rules.

Odds: Not going to happen

 

Repealing the individual mandate

Obamacare’s requirement that nearly all Americans have health insurance is unpopular, but as a centerpiece of the law, the individual mandate is critical to its function. Voiding the mandate would likely cause insurance premiums to rise steeply and would increase the uninsured rate, which the ACA has steadily brought down since its enactment. The mandate’s unpopularity means some Senate Democrats might feel pressure to vote for repeal, but President Obama has indicated he would veto such an action, saying Nov. 5, “The individual mandate is a line I can’t cross.”

Odds: Not going to happen

 

Repealing the medical device tax

Getting rid of one of the ACA’s revenue generators, a 2.3 percent tax on medical devices, had bipartisan support even before the recent midterm elections and is likely to come up for a vote soon. The medical device lobby is powerful and has made the case that the tax, which started in 2013, is being passed to consumers in the form of higher health care and insurance costs. The provision is expected to generate about $30 billion over ten years. The medical device tax, part of a package of new fees meant to offset costs of the ACA, is not critical to the law’s function and President Obama may agree to roll it back if he can get something in return.

Odds: Possible

 

Repealing, altering or delaying the employer mandate

The ACA requires that mid-sized and large employers provide health insurance to full-time workers. Most already did even before the law, but there’s evidence that the employer mandate is causing some companies to eliminate insurance for part-time workers or convert some full-time positions into part-time ones. The employer mandate has already been delayed multiple times, most recently earlier this year when the White House announced that medium-sized businesses would not have to comply with the provision until 2016. The requirement for large businesses is scheduled to begin in 2015, but given that the provision is not in effect for any companies yet and the White House has delayed it before means it’s a target for repeal or revision.

Odds: Possible

 

Eliminating the Independent Payment Advisory Board

The IPAB is an independent panel created by the ACA to lower Medicare payments to health care providers if Congress doesn’t act to keep the program’s spending under control. IPAB is somewhat unpopular—Republicans have erroneously dubbed it a “death panel”—but since the board seats aren’t even filled and it hasn’t taken any action, garnering enough support to get rid of it might be challenging.

Odds: Possible

 

Lower the minimum threshold for what insurance must cover

Health plans for sale through the ACA’s insurance marketplaces, or exchanges, all have minimum requirements for what they cover and limits on how much consumers must pay out of pocket. Aside from those under 30 or those who’ve been given special exemptions, who can comply with the individual mandate by purchasing high-deductible catastrophic insurance, everyone must have standard comprehensive health plans to meet the individual mandate. But Republicans have said cheaper plans that provide less coverage should be offered to more people and should meet the requirement to have insurance.

Odds: Unlikely

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