MONEY Health Care

4 Really Weird Things About the Latest Obamacare Ruling

U.S. President Barack Obama (L) walks out next to Vice President Joseph Biden
Obama's signature health-care law faces a new court challenge. Larry Downing—Reuters

An appeals court says Congress must have meant to make the health care law even more complicated than we thought.

Today two separate appeals courts handed down decisions on challenges to the Affordable Care Act, known popularly as Obamacare. One of those courts, a three-judge panel of the U.S. Court of Appeals for the D.C. Circuit, ruled that the federal government can’t provide insurance premium subsidies to people in states that haven’t set up their own insurance exchanges. The other court rejected that argument.

The D.C. circuit’s opinion, which would invalidate the subsidies paid to about 5 million people, will be a huge, huge deal if it holds up. Much of the early debate and legal wrangling over the ACA focused on the “individual mandate,” the part of law that fines you if you don’t have health coverage. But the subsidies are even more important because they make the required coverage affordable for moderate- to middle-income families. (The subsidies are available to a family of four earning up to $95,400.) The law says you don’t have to pay the fine if insurance isn’t affordable, so without the subsidies the mandate doesn’t apply to so many people.

The ruling could very well be overturned on appeal, and in the meantime the subsidies remain in place. (You can read more on what happens next in this report by Time’s Kate Pickert.) But as a reporter who has covered health care reform closely since the George W. Bush administration, I have to say this ruling just doesn’t make much sense to me. In particular, four very odd things stand out.

1. The court’s interpretation seems implausible.

Quick background: Obamacare subsidies are issued when you buy insurance on an online marketplace called an exchange. Some states set up their own exchanges, but 36 states didn’t, leaving the federal government to do the job instead. The D.C. Circuit ruled that the law authorizes the subsidies to be paid only through state-run exchanges.

This ruling hinges on a close reading of the law, a purported effort to figure out what Congress truly intended. The government, defending Obamacare, argued that because the law can’t work without the premium subsidies, Congress must have meant them to apply regardless of who ran the exchange.

But the court offered another theory: Maybe Congress meant the subsidies to be an incentive for states to set up their own exchanges.

That sounds like a implausibly flexible approach to what was meant to be a sweeping national health care law. After all, it essentially gives any state whose governor or legislature opposes the ACA a chance to opt out of some its biggest provisions—not just the subsidies, but the individual mandate, too.

Cast your mind back to the debate in 2009 and 2010. What I remember was conservatives denying the ACA a single Republican vote and arguing that Democrats would brook no compromise. Democrats, meanwhile, were pointing out that Obamacare looked a lot like the Massachusetts law signed by Republican governor Mitt Romney.

It seems to me that in a long argument over whether Obama and Nancy Pelosi and Max Baucus were tyrants, or just sweetly reasonable splitters-of-the-difference, someone might have said: “Hey, if Republican-led states don’t like the individual mandate, they can always opt out of the exchanges.”

That did not happen.

2. If the ruling stands, this messes up the insurance markets in 36 states.

If there are no subsidies, that doesn’t only mean that many people won’t get help from the government to buy coverage. Even those who didn’t get the subsidies in the first place could face higher prices.

That’s because the law requires the exchanges to sell insurance to everyone who applies, charge them the same rates (based on age) regardless of health, and offer a minimum package of benefits. The problem is that if you don’t have to buy insurance, many people will do so only when they know they need coverage—i.e., when they are sick. And if too few healthy people and too many sick people sign up, insurers have to raise prices to cover the costs. That then means you have to really sick to want to sign up, and that jacks up rates more, and so on. This is known in insurance as adverse selection, or a “death spiral.”

So the federal exchanges could stop working pretty quickly if this ruling stands. In fact, according to the briefs filed by the insurance industry and a group of economists who support the ACA, the adverse selection problem in the exchanges could spill over into the market for private individual plans outside the exchange too, since the law links the two markets in various way. How this would actually play out is unclear, but suffice it say, it’s a major rug-pulling.

Setting up federal exchanges that can’t work seems pretty dumb. Now, as Michael Cannon of the libertarian Cato Institute says, it’s not like lawmakers never make bad laws. States have tried to regulate insurance coverage the way the ACA does, without subsidies, and they’ve run into all these adverse selection problems. The thing is, people in Washington knew this when the ACA was being debated and written. It’s why the subsidies and the individual mandate—a wildly controversial, politically costly provision that many members of Congress wished would go away—were in the law in the first place.

3. This somehow involves the Northern Mariana Islands.

The D.C. Circuit panel notes that the ACA in fact did trigger the “death spiral” problem in this U.S. overseas territory in the Pacific. That’s because the Northern Mariana Islands were subject to the new rules about health coverage but left out of the subsidies. That, says the court, means that maybe Congress really could have meant to regulate the insurance market without subsidizing it too.

I can think of some other reasons why Congress might have klutzed up the part the law that applies to U.S. territories. Like the fact that people in those places have no voting representation in Congress.

4. Congress really isn’t very good at crafting laws

I don’t mean it’s not good at making laws (views may vary on that). I’m talking about the actual writing-it-down part. The court’s lead opinion is devastating in showing how badly written parts of the law are. If these were comments from the professor in a course titled “Lawmaking 101: Making a Bill a Law,” you’d expect to see a big fat red “D” at the bottom of Congress’ term paper. The bill was pushed through hastily after Republican Scott Brown unexpectedly won the late Ted Kennedy’s seat in the Senate, depriving the Democrats of a filibuster-proof majority. The craziness of the legislative process shows in the text.

But its not just a craft problem. The legal vulnerability of the ACA goes hand-in-hand with how politically vulnerable it is. The law makes sense in a basic way and seems to be helping more people get coverage. And polls say people like many of the provisions of the law. But it is also complicated, and hinges on many different players (states, employers, private insurers, Medicare, Medicaid, you and me…) interacting in predictable and not-so-predictable ways. From the beginning, many people have really struggled to get how the law fits together. Turns out that may have included some people in Congress.

MONEY Health Care

Court Ruling Puts a Key Provision of Obamacare in Doubt—For Now

U.S. President Barack Obama (L) walks out next to Vice President Joseph Biden.
Today's D.C. court ruling dealt a blow to Obama's signature legislative achievement, while another set of judges backed the president. Larry Downing—Reuters

A federal appeals court has struck down the premium subsidies offered on the federal insurance exchange, potentially undermining a major provision of the law and raising costs for millions of Americans. With another court upholding the law, more court battles lie ahead.

A three-judge panel at the U.S. Appeals Court for the D.C. Circuit threw the fate of an important part of the Affordable Care Act into doubt Tuesday. In a 2-1 decision in Halbig v. Burwell, the judges ruled that the Internal Revenue Service lacked the authority to allow subsidies to be provided in exchanges not run by the states. That could put at immediate risk the millions of people who bought insurance in the 36 states where these online insurance marketplaces are run by the federal government.

“Because we conclude that the ACA unambiguously restricts the section 36B subsidy to insurance purchased on the Exchanges ‘established by the state,’ we reverse the district court and vacate the IRS’s regulation,” said the decision by Judge Thomas Griffith.

Meanwhile, just an hour later, another three-judge panel on the 4th Circuit Court of Appeals in Richmond, Va., came to the opposite conclusion—upholding the federal subsidies.
“It is therefore clear that widely available tax credits are essential to fulfilling the Act’s primary goals and that Congress was aware of their importance when drafting the bill,” said the decision written by Judge Roger Gregory.

The Obama administration said it will appeal the Halbig decision. The Justice Department will ask the entire appeals court panel to review the decision, and that panel is dominated by judges appointed by Democrats, 7-4. The issue is also in other courts around the country.

White House spokesman Josh Earnest said: “There’s a lot of high-minded case law that’s applied here. There’s also an element of common sense that should be applied as well, which is that you don’t need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credits that would lower their health care costs, regardless of whether it was state officials or federal officials who were running the marketplace.”

‘’We believe that this decision is incorrect, inconsistent with Congressional intent, different from previous rulings, and at odds with the goal of the law: to make health care affordable no matter where people live. The government will therefore immediately seek further review of the court’s decision,” said a statement from the Justice Department.

Meanwhile, Elizabeth Wydra, chief counsel for the Constitutional Accountability Center, said the ruling wouldn’t take effect right away. “The court’s rules are that it doesn’t happen for 45 days,” to give the government time to ask for a full en banc hearing, “or 7 days after the en banc hearing has been denied.”

Should the decision eventually stand, however, it could mean at least five million Americans would face an average premium increase of 76%, according to a projection done by the consulting firm Avalere Health.

The court said that the wording of the health law “plainly makes subsidies available only on Exchanges established by states,” and that the legislative history of the bill “provides little indication one way or the other of congressional intent.”

But Judge A. Raymond Randolph offered a strong dissent. “It makes little sense to think that Congress would have imposed so substantial a condition in such an oblique and circuitous manner.”

The case could end up in the Supreme Court.

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

What the New Obamacare Court Decisions Mean for You

U.S. President Barack Obama speaks before signing the H.R. 803, the Workforce Innovation and Opportunity Act. during an event in the Eisonhower Executive Building, July 22, 2014 in Washington, DC.
U.S. President Barack Obama speaks before signing the H.R. 803, the Workforce Innovation and Opportunity Act. during an event in the Eisonhower Executive Building, July 22, 2014 in Washington, DC. Mark Wilson—Getty Images

Two federal courts, two conflicted rulings. What does it all mean?

On Tuesday, two federal courts issued rulings on President Obama’s healthcare law. Here’s what you need to know about how the rulings affect you:

What did the courts say?

A panel in the D.C. Circuit Court of Appeals ruled that the Affordable Care Act (ACA) does not allow the federal government to distribute insurance subsidies through a federal exchange being used in 36 states. Many states declined to set up their own insurance exchanges, forcing the federal government to set up its own central exchange where subsidized plans are sold. The D.C. court said that only people living in those states with their own exchanges are eligible for federal subsidies, due to ambiguities in the language of the ACA.

But in the Fourth Circuit Court of Appeals, judges reached the opposite conclusion. That panel ruled that the federal government does have the authority to hand out insurance subsidies through the federal exchange, and always intended subsidies to be available to any eligible individual in the U.S., regardless of who is running the exchange.

What happens next?

The federal government will appeal the D.C. court ruling and plaintiffs in the identical case in the Fourth Circuit will also likely appeal. The issue is likely to remain unsettled for many months.

What does this mean for Americans currently getting insurance through the ACA?

Nothing yet. With conflicting rulings on the same day and appeals certain, the status quo will remain in place — for now.

But if the D.C. ruling ends up being upheld and the Fourth Circuit overturned, the consequences would be immense. By 2016, more than 7 million people are set to receive ACA insurance subsidies through the federal exchange at the center of each of Tuesday’s rulings. These subsidies are now under threat, and could disappear in those 36 states if the D.C. ruling is upheld on appeal.

Without subsidies, millions in those states could see their insurance premiums go up dramatically. The ACA requires most Americans to have health insurance but only if they can afford it. Without subsidies, coverage for millions would become unaffordable. Removing these people from the health insurance pool could destabilize premiums for everyone else.

What would that mean for Obamacare?

It would be a hammer blow, if the D.C. ruling stands. The government would no longer be able to distribute insurance subsidies in those 36 states, unless those states opted to set up their own exchanges. That would be unlikely, since many of the states that declined to set up exchanges did so in protest at the ACA. The subsidy system is a central feature of Obamacare and Democrats’ plan to expand insurance coverage to low- and middle-income Americans.

Opponents of the law have sued over the ACA before. What makes this case different?

A ruling that threatens to strip insurance subsidies from millions of Americans is the most significant threat to Obamacare since it overcame the challenge to its constitutionality in the U.S. Supreme Court in 2012 — though that same ruling made its Medicaid expansion optional and not mandatory, blocking millions of low-income Americans from coverage. Legal arguments made against Obamacare since have not struck at the heart of the law’s goal of expanding coverage. The recent Hobby Lobby lawsuit, for example, only affected contraception coverage for some employer health plans.

TIME Congress

Boehner: House Will Sue President Over Obamacare Employer Mandate

Speaker of the House John Boehner speaks to the media on Capitol Hill in Washington
Speaker of the House John Boehner (R-OH) speaks to the media on Capitol Hill in Washington, July 10, 2014. Joshua Roberts—Reuters

House Speaker John Boehner says says the suit is based on the fact that Obama revised the Affordable Care Act mandate without approval from Congress

House Speaker John Boehner announced Thursday that the chamber will sue President Barack Obama for delaying the Affordable Care Act’s employer mandate last year.

The decision gave companies with at least 50 full-time employees an extra year to provide health insurance or face a fine. Earlier this year, the Administration delayed the mandate until 2016 for companies employing between 50 and 99 workers.

“Today we’re releasing a draft resolution that will authorize the House to file suit over the way President Obama unilaterally changed the employer mandate,” wrote Boehner in a public statement. “In 2013, the president changed the health care law without a vote of Congress, effectively creating his own law by literally waiving the employer mandate and the penalties for failing to comply with it. That’s not the way our system of government was designed to work. No president should have the power to make laws on his or her own.”

Democrats immediately ridiculed the measure as a political stunt.

“Instead of working to create jobs, instead of working to strengthen the middle class or addressing any of the urgent issues facing our nation, Republicans are wasting taxpayer dollars on another toxic partisan stunt,” wrote Drew Hammill, a spokesman for Democratic Leader Nancy Pelosi, in a public statement. “This lawsuit is just another distraction from House Republicans desperate to distract the American people from their own spectacular obstruction and dysfunction.”

TIME Barack Obama

Obama’s ‘Between Two Ferns’ Episode Nominated for an Emmy

Obama Visits Tech Hub
U.S. President Barack Obama speaks about the economy at the technology start-up hub "1776" July 3, 2014 in Washington, DC. Pool—Getty Images

Obama himself won't get an Emmy, though

An episode of online comedy series “Between Two Ferns with Zach Galifianakis” featuring President Barack Obama was among the Emmy nominees announced Thursday morning.

The six-minute, 30-second episode featuring the President has been nominated for Outstanding Short-Format Live-Action Entertainment Program. It was first published on the humor website Funny or Die on March 11. Galifianakis’ show sees the actor interview a string of famous guests whom he asks inappropriate and awkward questions.

Though Galifianakis is biting, he’s no match for the President who, when asked if he wishes he could run a third time, replies: “Uh, if I ran a third time, it’d be sorta like doing a third Hangover movie. It didn’t really work out very well, did it?”

Obama then proceeds to try and educate Galifianakis about the Affordable Care Act and registering with Healthcare.gov online or by phone. Galifianakis responds: “I’m off the grid. I don’t want you people, like, looking at my texts.”

While Obama himself is not up for an Emmy for the episode, he has previously received the Grammy for best spoken word album for Dreams from My Father and The Audacity of Hope in 2006 and 2008, respectively.

The 66th Primetime Emmy Awards will be broadcast on August 28 at 8 p.m. ET on NBC. Actor Seth Meyers is hosting this year’s awards.

MONEY Health Care

Why Your Boss Isn’t Dropping Your Health Plan (Yet)

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Obamacare requires most employers to offer coverage next year, but fears persist that many will dump workers onto the insurance exchanges instead. Fear not, for now.

Q: I’ve heard that some firms may drop their health plans and have workers purchase a plan on the government exchanges. Will that happen to me?

A: Nine months after the launch of the controversial health insurance exchanges, confusion hasn’t died down over what exactly health reform means for the average American. A new poll found that 65% of workers are very or somewhat worried that their firms will drop health coverage and have employees go it alone on the new federal and state insurance exchanges.

Such a move would hurt, at least in workers’ minds, according to the survey of 1,240 likely voters by Morning Consult, a digital media company. Half said that if their employer exited the benefits business, they would be negatively affected; only 16% expected to benefit from such a switch.

Even though Obamacare requires firms with 50 or more workers to offer insurance or owe a fine starting in 2015, the concern is that some will opt to pay the fine, since individual coverage can cost two to three times as much—and substantially more for a family plan. What’s more, employers with fewer than 50 workers that already offer health benefits—even though they are not required to—may decide to get out of the business now that all workers have the alternative of buying coverage on an exchange.

Are workers right to worry about getting dumped? As long as you work for a large firm, you shouldn’t lose sleep over the issue, at least not yet, says Beth Umland, director of research for health and benefits at consultant Mercer. Earlier this year—well after the exchanges went live—an overwhelming 94% of big firms reported that they will keep offering health coverage for the next five years, Umland says. That percentage has remained consistent since Mercer first asked the question in 2008.

Separate research from the National Business Group on Health, which represents large employers, also found about 95% of those firms plan to stick with the status quo, says CEO Brian Marcotte.

A wait-and-see approach

Big business remains committed for lots of reasons, experts say. For one, good benefits are crucial to attracting talent. More than 90% of workers say health-care benefits are as important as pay, according to Mercer. In the Morning Consult poll, more than half of respondents say they would consider looking for a new job if they had to shop for coverage.

Company leaders are also uncertain about how premiums and plan features on the individual market will evolve after last year’s shaky launch. Until the exchange offerings become more predictable, executives are unlikely to send their employees there, with or without a subsidy to buy coverage, says Tracy Watts, who leads the health care reform group at Mercer.

Even then, large firms may not go that route. “The math doesn’t work for most firms,” says Watts. Today your boss pays its share of your health premium with pre-tax dollars. If the firm decides to offer you a subsidy to buy your own plan instead, the loss of that tax benefit means it would likely have to dole out more for you to get the same plan—or risk facing worker backlash.

Smaller firm, bigger risks

You’re more likely to be moved to an exchange if you’re at a firm with fewer than 50 workers. About one-third of small businesses that offer coverage today say they are considering getting out of the game, up from only 23% a year ago, says Mercer’s Umland.

You also face a higher likelihood if you work at a firm with a large low-wage or part-time workforce, such as a store or hotel, says Marcotte. Many firms in those industries do not offer health insurance to all their workers today. Rather than add them to the plan, companies may decide workers are better off on the exchanges, where they can qualify for government subsidies only if their boss fails to offer an affordable plan.

Keep in mind that while most firms say they’ll remain in the game for the foreseeable future, they’re not nearly as confident over the long haul. “Health care is changing pretty rapidly right now,” says Marcotte. “So they’ve got to look at it every year.” By then, though, you too should have a better sense of how you’d fare on your own too.

TIME Religion

After Hobby Lobby: A Single-Payer Health Care Solution?

Perhaps both sides could agree it may be a way forward

Now that the initial shouting and—at times—vitriol from both sides has subsided after Monday’s Supreme Court ruling in the Hobby Lobby case, it’s time to take a sober look at what the ruling says about the future of health care reform in the United States. The majority’s ruling was an imperfect solution to a complicated case involving the reach of religious liberty to exempt organizations from providing certain medical benefits that they find morally objectionable to their employees. The fact that these medical benefits were almost exclusively offered to women makes this decision all the more difficult to accept for some.

But at its core, the case reveals something else as well. It brings to the forefront something we’ve all known for sometime: that Obamacare—for all the good it’s done in increasing access to quality and affordable healthcare—is a messy law. It asks employees to be at the whim of its employers’ objectives and mission for what health care benefits they receive. It also asks employers to at times reject its deepest convictions in order to provide certain benefits to its employees.

This isn’t sustainable. A person’s access to quality healthcare shouldn’t depend on who their boss is. And an employer shouldn’t be heavily fined if they don’t compromise their religious convictions in providing healthcare for their staff.

President Obama’s Affordable Care Act is a monumental first step in achieving a just and equitable American health care system that seeks first to serve those on the margins of society. But as we look towards the future, it’s necessary to consider major alterations or even alternatives to Obamacare to continue to advance healthcare reform.

For those of us who value both universal access to quality healthcare and the strong American tradition of protecting religious liberty, there might be a solution in a single-payer system.

A single-payer system overturns an unsound principle of Obamacare: relying too heavily on private organizations to deliver the public good of healthcare. When you require private organizations to enforce what the government believes ought to be public policy, you open yourself to a myriad of legal and ethical qualms. How can you expect organizations as diverse as Hobby Lobby, the Little Sisters of the Poor and the American Atheists to agree on what health care benefits are appropriate for their employees?

Amidst all the fuss this week over the Supreme Court ruling, both sides actually agreed on one thing: they disliked the accommodation provided by the Obama Administration for religious organizations. Religious groups argue the exemption is too narrow and doesn’t protect the autonomy of some organizations to practice their convictions. Women’s groups argue that the current accommodation unfairly denies women working for religious groups access to birth control, which is a basic benefit in any healthcare plan.

A single-payer public health care option eliminates such complications. No matter who your boss is or what business you work for, you get access to the healthcare you need. And employers will not be forced to compromise their religious beliefs while providing the public good of healthcare.

And let’s be clear, if you have something that is both supported by the United States Conference of Catholic Bishops and Planned Parenthood, you might be onto a plan that proves the angel Gabriel right: nothing is impossible with God.

Fred Rotondaro is the chair of Catholics in Alliance for the Common Good and a senior fellow at the Center for American Progress. Christopher Hale is a senior fellow at Catholics in Alliance for the Common Good. He helped lead national Catholic outreach for President Obama’s re-election campaign.
TIME Healthcare

20 Million Americans Get Insurance Under Obamacare, Report Says

A new report estimates millions of Americans have enrolled in health insurance as of this Spring

About 20 million Americans have gained health insurance or enrolled in new insurance under the health care reform law, according to a new report.

The report from the Commonwealth Fund, published Wednesday in the New England Journal of Medicine, credits President Barack Obama’s health reform law with an estimated 20 million enrollments as of May 1. The report looks at both people who gained coverage through insurance marketplaces, and people who gained coverage due to provisions in the Affordable Care Act (such as those qualifying for Medicaid and those now covered through the Children’s Health Insurance Program).

The authors estimate that 7.8 million people under 26—who are now allowed to be covered as dependents on their parents’ plans—have enrolled. They also report that 8 million people were enrolled in coverage via new health insurance marketplaces and five million purchased coverage directly from insurers.

The authors write that for ACA’s continued expansion to be sustainable, it will rely largely on the ability of the U.S. to control health care costs.

“Developing and spreading innovative approaches to health care delivery that provide greater quality at lower cost is the next great challenge facing the nation,” the report concludes.
The Commonwealth Fund
MONEY Health Care

What the Supreme Court Birth Control Ruling Means to You

Activists holding signs about Hobby Lobby case standing outside the Supreme Court
Activists outside the Supreme Court on March 25, 2014, when Sebelius v. Hobby Lobby Stores was argued. BRENDAN SMIALOWSKI—AFP/Getty Images

Thanks to Obamacare, most health plans have fully covered contraception since 2013. Will the Hobby Lobby court decision change what you pay? Here’s the lowdown.

This morning the nation’s highest court weighed in on a topic usually reserved for the doctor’s office or bedroom. In a 5-4 vote, the court ruled that the Affordable Care Act cannot require closely held, for-profit corporations to provide health insurance that covers contraception services for women when those services go against their religious beliefs. The anxiously awaited decision could have far-ranging implications for religious freedom and health reform.

Women and their partners, though, are likely wondering what the decision means for the cost of birth control. Here’s what you need to know.

What is the health insurance benefit at the center of this fight?

Starting last year, you no longer had to fork over any cash to buy contraception (aside from the premium you paid). Under Obamacare, most insurance plans, both individual and group policies, must fully cover preventive services designed to keep you healthy, such as mammograms, colonoscopies, and many vaccinations. After the Affordable Care Act was passed, the Institute of Medicine recommended that contraception be included on that list of no-cost services, says Judy Waxman, the vice president for health and reproductive rights at the National Women’s Law Center.

That has meant that most health plans must cover the full range of contraceptives approved by the Food and Drug Administration, including pills, rings, patches, shots, implants, intrauterine devices, barrier methods, and sterilization procedures. For each of these services, as long as you have a prescription from the doctor, you’ll pay nothing.

There are a few nuances. For example, if a drug comes in a generic version and you opt for the brand name, you may owe a co-pay or co-insurance (although there is a waiver process that grants you access to the premium drug at no cost if your doctor asserts you need it for a medical reason).

Previously, large group plans typically covered contraception but you had to cover a co-pay or co-insurance, according to David Dross, who runs the pharmacy practice at benefits consultant Mercer. You also owed your deductible before the coverage kicked in. So you may have paid the full cost for, say, ten months.

On Friday the Department of Health and Human Services announced that an additional 24.4 million prescriptions for oral contraceptives were given out with no co-pays in 2013 compared to 2012.

So what was the legal battle over?

In this case two for-profit companies, the big box craft chain store Hobby Lobby and cabinet maker Conestoga Wood, argued that they view certain types of contraception, such as morning after-pills Plan B and ella, akin to abortion and in violation of their Christian religious beliefs. They asked to be exempt from paying for those services.

Will the ruling change my insurance coverage?

If you work for a large, publicly traded company, the decision will likely not change what your birth control costs, says Waxman. The ruling specifies that only “closely held” firms, or those owned by a small number of individuals, with sincerely held religious beliefs can qualify for an exemption. So you’re unlikely to see a Fortune 500 company strip these services from their health plans any time soon.

While it’s unclear how many firms could potentially qualify for the exemption, workers at any firms that do won’t necessarily be left paying for their pills. “The administration will likely by regulation put some type of work-around in place,” to give workers the benefit, says Tim Jost, a law professor and Affordable Care Act expert at Washington and Lee University. “I just don’t know how long it will take them to do it. They may be prepared to do it very quickly.”

What if I work at a non-profit with a religious affiliation, such as a Catholic hospital or university?

Religious organizations such as churches were already exempt from the requirement that they cover all types of FDA-approved contraception. Separately, religious-affiliated non-profits, including universities and hospitals, were granted a workaround by the Obama administration. Workers in those firms still have access to contraception at no cost. The companies simply turn over the administration and cost to the health insurer. There are legal suits working their way through the court system fighting this accommodation, though. Based on today’s ruling, Jost says it seems that the court may be implicitly saying this work-around is permissible.

TIME Health Care

4 Reasons the Supreme Court Contraception Ruling Means Less Than You Think

Supreme Court Hobby Lobby Protesters
Anti-abortion demonstrators cheer as the ruling for Hobby Lobby was announced outside the U.S. Supreme Court in Washington on June 30, 2014. Jonathan Ernst—Reuters

The justices who supported it tried hard to limit the decision’s scope

When the Supreme Court ruled Monday that some corporations could opt out of providing insurance coverage for contraception, the abortion rights group NARAL Pro-Choice America characterized the decision as “a slippery slope with no end.” But a close look at the ruling reveals that the five justices who supported it tried hard to limit the decision’s scope. Here’s why the 5-4 ruling means less than you might think:

The ruling only applies to “closely held” corporations

According to the IRS, a company is closely held if five or fewer people own more than half the corporation. A family-owned private business like Hobby Lobby qualifies, but most publicly traded for-profit corporations do not. Some critics of the decision point out that more than 90% of all corporations in the U.S. are “closely held,” but a significant portion of these are so small they are not subject to the Affordable Care Act’s mandate that’s the subject of the Hobby Lobby case anyway. The so-called employer mandate says companies with 50 or more workers must provide health insurance.

Women who work for Hobby Lobby had, and still have, full insurance coverage for most types of birth control

Although the Supreme Court ruling opens the door for closely held companies to make other future objections based on religious beliefs, Hobby Lobby’s individual position is less extreme than many believe. The company objects to paying for morning-after pills and inter-uterine devices, but freely provides insurance that covers tubal ligation, birth control pills, condoms, diaphragms and contraception delivered via a patch or ring inserted into the cervix. More than 80% of all contraception users in the U.S. rely on these methods.

Employees of Hobby Lobby may still be able to get 100% insurance coverage for all types of birth control—it just won’t be paid for by the company

The Supreme Court ruling means Hobby Lobby does not have to pay for contraception it objects to on religious grounds, but the federal government is free to provide such coverage, and could easily do so. When the Obama Administration said in 2012 that large nonprofit religious institutions like Catholic hospitals and colleges did not have to provide birth control coverage, it created a mechanism for insurers to provide the coverage without the employers paying premiums to support it. Such compromises have characterized the Administration’s approach to balancing religious liberty with the Affordable Care Act’s rules on birth control and abortion coverage. But there are some circumstances that remain unclear. In a case still pending in the courts, a nonprofit religious organization, Little Sisters of the Poor, has refused to sign a form that would essentially allow it to opt out of providing birth control coverage so that another entity could provide it instead. Doing so, the group says, is akin to signing “a permission slip” for birth control and abortion. It seems unlikely that Monday’s ruling will settle the issues in that case; the Supreme Court could rule on it next term.

The court appeared to rule out using the Hobby Lobby decision to argue in the future that employers can object to covering drugs, devices, treatments and procedures not related to birth control

In the majority opinion, Justice Samuel Alito wrote, “This decision concerns only the contraceptive mandate and should not be understood to hold that all insurance-coverage mandates, e.g., for vaccinations or blood transfusions, must necessarily fall if they conflict with an employer’s religious beliefs.”

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