MONEY Health Care

How Some Insurers Still Avoid Covering Contraception

Locked up birth control pills
Nicholas Eveleigh—Getty Images

Under health reform, your birth control should be fully paid for by insurance. But even before the Supreme Court gave more employers an out, some insurers have been pushing back.

How much leeway do employers and insurers have in deciding whether they’ll cover contraceptives without charge and in determining which methods make the cut?

Not much, as it turns out, but that hasn’t stopped some from trying.

Kaiser Health News readers still write in regularly describing battles they’re waging to get the birth control coverage they’re entitled to.

In one of those messages recently, a woman said her insurer denied free coverage for the NuvaRing. This small plastic device, which is inserted into the vagina, works for three weeks at a time by releasing hormones similar to those used by birth control pills. She said her insurer told her she would be responsible for her contraceptive expenses unless she chooses an oral generic birth control pill. The NuvaRing costs between $15 and $80 a month, according to Planned Parenthood.

Under the health law, health plans have to cover the full range of FDA-approved birth control methods without any cost sharing by women, unless the plan falls into a limited number of categories that are excluded, either because it’s grandfathered under the law or it’s for is a religious employer or house of worship. Following the recent Supreme Court decision in the Hobby Lobby case, some private employers that have religious objections to providing birth control coverage as a free preventive benefit will also be excused from the requirement.

In addition, the federal government has given plans some flexibility by allowing them to use “reasonable medical management techniques” to keep their costs under control. So if there is both a generic and a brand-name version of a birth-control pill available, for example, a plan could decide to cover only the generic version without cost to the patient.

As for the NuvaRing, even though they may use the same hormones, the pill and the ring are different methods of birth control. As an official from the federal Department of Health and Human Services said in an email, “The pill, the ring and the patch are different types of hormonal methods … It is not permissible to cover only the pill, but not the ring or the patch.”

Guidance from the federal government clearly states that the full range of FDA-approved methods of birth control must be covered as a preventive benefit without cost sharing. That includes birth control pills, the ring or patch, intrauterine devices and sterilization, among others.

But despite federal guidance, “we’ve seen this happen, plenty,” says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. “Clearly insurance companies think things are ambiguous enough that they can get away with it.”

If you are denied coverage, your defense is to appeal the decision, and get your state insurance department involved.

“The state has the right and responsibility to enforce this law,” says Sonfield.

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.

More on the Affordable Care Act and contraception coverage:

 

 

 

 

 

MONEY Health Care

What It Really Means When Your Doctor Says He Doesn’t Take Insurance

A denial may not be as straightforward as it seems. Here's what your doctor's policy could be—and what that could mean for your medical bills.

Some doctors really mean it when they say they do not take health insurance. For others, it is more of a nuanced statement.

Consumers trying to decipher the difference have to ask a lot of questions to figure out how to manage their bills.

Here are the three key scenarios facing consumers:

1. “I do not take your insurance, but I will work with you on the price.”

A growing number of doctors simply are not taking contracts with insurance companies, although the concentration varies by region and by specialty. That leaves patients to pay the market rate the doctor charges, and then submit a receipt to get reimbursement for out-of-network coverage, if they have it.

In some cases, the pickings can be slim for in-network docs. For example, 45% of psychiatrists do not participate in insurance networks, according to JAMA Psychiatry.

“The burden of getting the forms right and getting all the paperwork is placed on the physician,” says Dinah Miller, a psychiatrist who practices in Baltimore and co-authors a blog called Shrink Rap. “If you’re seeing eight or nine patients a day, and several bounce, it’s a lot of uncompensated time.”

Primary care physicians are opting out, too. Some are moving to a concierge model, in which patients pay a subscription fee like $150 a month to see their doctor.

Membership in the Association of American Physicians and Surgeons, a conservative-libertarian group of private-pay doctors, increases by about 10% a year, says Jane Orient, executive director of the organization, which has 5,000 members.

Many doctors who say they don’t take insurance will make deals with patients on an individual basis. One key negotiating tip is to know what your in-network rate would be, typically a discount of about 40%, suggests Joe Mondy, a spokesman for insurer Cigna.

You can get this information through your provider’s online tools or by calling the customer service line. But Mondy says to be aware that the private provider is not bound to accept that price.

2. “I will submit the receipt for you, see what I get from the insurance company and work with you on the difference.”

This process is typically referred to as balance billing. It is largely frowned upon for in-network charges, and even restricted in some states. But it still goes on in the private-pay world, and often results in a confusing morass of paperwork.

Even insurance executives find themselves negotiating the fray. Chris Reidl, director of product for national accounts at insurer Aetna, paid an up-front fee to one doctor and then submitted the bill to the insurance company. When the insurance company reimbursed the doctor for the visit, the office refunded the fee she had paid.

Consumers need to be on top of this process and pour over their benefits statements to track the various payments. They also need to keep after their doctors’ offices to get their money back.

3. “I will try to negotiate a better rate with your insurance company.”

Some providers have back-channel communications with insurance companies, trying to get a better reimbursement so their patients end up paying less out of pocket.

Amy Gordon, a lawyer focusing on benefits issues at McDermott, Will & Emery in Chicago, facilitates some of these discussions, trying to get everyone on the same page.

Gordon gives the example of a chiropractor who has a number of patients on one employer’s plan. The going rate for a visit is $200, and the out-of-network reimbursement offered is $50. The provider has to choose whether to charge the patients the remainder or discount it.

“Being out $150 for one person is bad, but being out that much for 10 people is worse,” she says. So the provider tries to get more from the insurance company, and the insurance company tries to get the provider to join its network. The insurer and the doctor may end up settling on an $80 reimbursement, and the patients only have to pay the equivalent of a $20 co-pay.

“A lot of this can be avoided with planning, and finding if there is an acceptable in-network provider,” Gordon says. “If you still want to go out of network, you can ask the insurance company to give you an estimate of what they would pay, and then you can at least make a more informed decision.”

MONEY Health Care

How to Pick a Health Plan That’s Right For You

Picking a card with medicine on it
David Emmite—Getty Images

HMO, PPO, EPO? The alphabet soup of insurance plans may leave you dazed and confused. Here's how to make sense of your choices and get the coverage you need.

What’s in a name? When it comes to health plans sold on the individual market, these days it’s often less than people think. The lines that distinguish HMOs, PPOs, EPOs, and POS plans from one another have blurred, making it hard to know what you’re buying by name alone—assuming you’re one of the few people who know what an EPO is in the first place.

“Now, there’s a lot of gray out there,” says Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms.

Ideally, plan type provides a shorthand way to determine what sort of access members have to providers outside a plan’s network, including cost-sharing for such treatment, among other things. But since there are no industry-wide definitions of plan types and state standards vary, individual insurers often have leeway to market similar plans under different names. In general:

  • Health maintenance organizations (HMOs) cover only care provided by doctors and hospitals inside the HMO’s network. HMOs often require members to get a referral from their primary care physician in order to see a specialist.
  • Preferred provider organizations (PPOs) cover care provided both inside and outside the plan’s provider network. Members typically pay a higher percentage of the cost for out-of-network care.
  • Exclusive provider organizations (EPOs) are a lot like HMOs: They generally don’t cover care outside the plan’s provider network. Members, however, may not need a referral to see a specialist.
  • Point of Service (POS) plans vary, but they’re often a sort of hybrid HMO/PPO. Members may need a referral to see a specialist, but they may also have coverage for out-of-network care, though with higher cost sharing.

Although insurers identify plans by type in the plan coverage summaries they’re required to provide under the health law, one PPO may offer very different out-of-network coverage than another.

“You have PPOs with really high cost sharing for out-of-network services, which from a consumer perspective seem a lot like HMOs,” says Corlette. Some plans labeled as PPOs don’t offer out-of-network services at all, experts say. On the other hand, some HMOs have an out-of-network option that makes them seem similar to PPOs.

Then there are EPOs. “People have no idea what an EPO is,” says Jerry Flanagan, lead staff attorney at Consumer Watchdog, an advocacy organization that recently filed a class action lawsuit against Anthem Blue Cross in California. They claim, among other things, that the insurer enrolled people in EPO plans with no out-of-network coverage who believed they were being enrolled in PPO plans that provided such coverage.

“Materials at the time of enrollment and in member’s Explanation of Benefits have clearly stated that the plan was an EPO plan which may not have out-of-network benefits,” said Darrel Ng, a spokesperson for Anthem Blue Cross, in a statement.

This year, HMOs and PPOs dominated the plans offered by insurers on the health insurance exchanges. According to an analysis of plans sold in the 36 states for which the federal government runs the online insurance marketplace as well as the plans sold on the California exchange, HMO offerings made up 40% and PPOs another 40%. POS plans made up 12% and EPO plans 7%.

Higher premiums didn’t necessarily correlate with better out-of-network coverage, says Caroline Pearson, vice president at Avalere Health, a research and consulting firm. HMO plan premiums, in fact, were slightly higher on average than those for PPOs, according to the Avalere analysis.

Pearson says the explanation may be that insurers anticipated that people who bought a PPO would probably want to use out-of-network providers. Since out-of-network spending doesn’t count toward the out-of-pocket maximum that people are responsible for before insurance picks up the full tab, these people were likely to be cheaper to insure, she says. (Next year, the out-of-pocket maximum will be $6,600 for single coverage and $13,200 for a family plan.)

Based on the 18 states that have released their proposed products and rates for next year, it doesn’t appear that plan types are likely to change significantly, says Shubham Singhal, leader of the health care practice at management consultant McKinsey & Co.

“Perhaps a few more EPOs will emerge,” he says. “Some of the health plans that might have introduced metal-level plans through the HMO are viewing the EPO as way to introduce a non-gatekeeper product.”

Since you can’t rely on plan type to provide clear guidance on out-of-network coverage, there are three basic questions to investigate when evaluating a plan, says Pearson:

  • Is there out-of-network coverage?
  • Does that out-of-network spending accrue toward the member’s out-of-pocket maximum? Legally it doesn’t have to, but some plans include it.
  • Do members need a primary care physician gatekeeper?

That’s only the beginning. Once you figure out whether a plan covers out-of-network care, it can be difficult to find out whether your doctor is even in that plan. You can check with you doctor’s office, but sometimes they don’t know. You can also look at provider directories to see who is and isn’t in a plan’s network, however, that information frequently proved inadequate or inaccurate last open enrollment period. But understanding the alphabet soup of plan types is an important first step.

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.

MONEY Ask the Expert

When Parents Can Say No to Picking Up the Tab for Insurance

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Q. My ex-husband has been responsible for providing health insurance for our kids until the age of majority. My sons are now 21 and almost 18. My ex has family coverage for himself and his new wife, but he wants me to put the kids on my insurance now that they have reached the age of majority. Covering the kids doesn’t cost him anything extra, but for me to switch from a single plan to a family plan is an extra $175 a month and I can’t afford it. Since the age of majority for health insurance is now 26, is it possible he still is required to keep them on his insurance?

A. No, he’s not obligated to keep them on his health plan. Under the health law, insurers must offer to cover young adults up to age 26, but parents aren’t obligated to provide it, says Timothy Jost, a law professor at Washington and Lee University and an expert on the health law.

Further, the requirement to offer coverage isn’t related to the age of majority, which is defined by individual states and is generally between 18 and 21, says Randy Kessler, an Atlanta divorce lawyer and past chair of the American Bar Association’s family law section.

The health insurance coverage arrangement that you describe is pretty typical, says Kessler. You could go back to court and try to get your child-support payments increased to cover the cost of providing health insurance for the kids, but “it would be unusual for the courts to be helpful,” says Kessler. Absent some significant change in your or your ex-husband’s finances, or unforeseen and costly medical expenses for your children, in general “you can’t have another bite at the apple.”

With no legal requirement to compel either of you to cover your kids, it’s something the two of you will just have to work out, says Kessler. In addition to covering your children on your own or your ex’s plan, it’s also worth exploring whether they might qualify for subsidized coverage on the state marketplaces or for Medicaid, if your state has expanded coverage to childless adults. If they’re in college, student health coverage is worth investigating as well.

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.

MONEY Health Care

How to Fix Your Finances…By Fixing Your Blood Pressure

Blood Pressure Gauge
Anthony Harvie—Getty Images

High blood pressure is hazardous to more than your health. Here's how to ease the impact on your finances.

High blood pressure affects one in three adults in the United States. It can have a major impact on your health, of course; as a financial planner, I’m also conscious of the negative consequences it can have for your finances, too.

The challenge with high blood pressure is that it does not cause a person to feel ill. With health care costing as much as it does, it is easy to forgo treatment for an illness that doesn’t cause many symptoms. So many people leave their high blood pressure untreated.

The end result of this inaction: greater illness and higher health care costs down the road. Untreated high blood pressure leads to heart disease, strokes, or heart and kidney failure. Not treating high blood pressure is a perfect example of being penny-wise and dollar-foolish.

So given the importance of treating high blood pressure, what can people do to control the current cost of their illness? A couple of actions can go a long way.

Improve Your Lifestyle

An unhealthy lifestyle is the most common way people develop high blood pressure in the first place. Weight loss, regular exercise, salt reduction, and limiting alcohol are cheap ways to potentially eliminate the disease. These aren’t easy changes at first, but by developing a new lifestyle as a habit, the new behavior gets easier with time.

A healthy diet is also important, but a diet heavy in vegetables, fruit, and unprocessed food can cost a lot and require time-consuming amounts of cooking. One way to mitigate this cost is to become an “Iron Chef”: work with the raw material at hand. Go with what’s on sale in the grocery aisle, or even better, hit the farmer’s market. Spend a couple of hours on days off to cook enough to last most of the week.

Manage Your Medicine

Doctors choose medication to treat high blood pressure based on a number of factors. Concurrent illness, other medication, demographics, and potential side effects all play a role. The good news is that most medication used to treat high blood pressure comes in generic form, and the generics work just fine. Generics are cheap. In fact, some pharmacies will provide generic medication for high blood pressure for free! Your doctor will know if these opportunities are available in your area; it’s up to you to ask about the options.

The most important part of medication management is consistency. Medication taken regularly and about the same time everyday results in better blood pressure control. Ideally, people brush their teeth every day, so why not put your medication by the toothbrush and make it part of the routine?

If your blood pressure is too high, the doctor will see you every couple of weeks or so until it is in a good range. If blood pressure is well controlled with lifestyle and medication, doctor visits are reduced to once or twice a year, depending on other health issues. Better control results in fewer doctor visits, which reduces the cost of care.

High blood pressure doesn’t have to be costly. By being forward-thinking about it, you can greatly improve the quality and length of your life — and lower your expenses along the way.

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Carolyn McClanahan is a physician, financial planner, and founder of Life Planning Partners. In addition to running her financial planning practice, she educates financial planners, health care professionals, and the public on the intersections of health and personal finance.

MONEY Health Care

WATCH: Walmart Wants to Be Your Doctor

Walmart is testing in-store health clinics in select parts of Texas and South Carolina.

MONEY Health Care

How to Find Health Coverage To Fill a Gap

Short-term insurance plans have major shortcomings, but having one will at least protect your from catastrophic costs.

Consumers who missed open enrollment on the state health insurance marketplaces this spring or who are waiting for employer coverage to start don’t have to “go bare.” Short-term policies that last from 30 days up to a year can help bridge the gap and offer some protection from unexpected medical expenses. But these plans provide far from comprehensive coverage, and buyers need to understand their limitations.

In contrast to regular health plans, applicants for short-term coverage may be rejected because they have pre-existing medical conditions.

Even if they’re accepted by the plan, the drugs and medical care necessary to manage their diabetes, for example, generally wouldn’t be covered, says Carrie McLean, director of customer care at online health insurance vendor ehealth.com.

Nor do short-term plans typically cover preventive care or pregnancy and maternity services.

“It’s not going to function like a regular health plan,” says McLean.

Lifetime coverage maximums are typical as are high deductibles. Between April and June, the average deductible for short-term individual plans sold by ehealth.com was $3,391, while families faced an average deductible of $8,252. Premiums averaged $107 for individuals and $249 for families.

Plans with similar limitations and restrictions used to be commonplace on the individual market. But the health law changed that. Today, regular insurance plans sold on the individual and small group markets must all cover a comprehensive set of 10 “essential health benefits,” and they can no longer turn people away because they have pre-existing medical conditions.

The 2014 enrollment for these plans ended in March, but some people who have specific changes in their life, such as losing job-based coverage or having a baby, can still get a special enrollment period to sign up for regular insurance plans.

Because short-term plans don’t meet the standards of the health law for “minimum essential coverage,” they also expose consumers to the health law penalty for not having health insurance of $95 or 1% of income, whichever is greater.

So why would someone buy a short-term plan, anyway? Basically, it provides some protection against catastrophic hit-by-a-bus expenses. Some consumers are looking for just that.

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.

Read more about the impact of health reform:

MONEY Health Care

Here’s One Thing That’s Cheaper in the City, and It Will Help You Live Longer

New York City Cityscape
Hint: It's not rent. Charles Taylor Crothers—GalleryStock

In some states, rural residents are paying far more for health insurance. Here's why—and why that might change next year.

By many measures, city living is a racket: skyrocketing rents, expensive food, and pricy entertainment options can make for a high cost of living. But a new study from the Robert Wood Johnson Foundation finds that city residents have the slight edge on one metric: this year they had access to cheaper individual health insurance plans on the state and federal exchanges that were created under Obamacare.

Nationally, rural residents pay only slightly more: A 50-year-old nonsmoker from a rural county is spending $387 a month on average for a mid-tier silver plan in 2014, while a city denizens pay $369 for the same kind of plan, the study found. But in some states the gap is much wider.

In Nevada, for example, residents of rural counties must spend an average of $554 a month for a silver plan—57% more than their urban peers. In eight other states, country consumers are charged at least $50 a month more for the same healthcare coverage.

A chief reason for higher premiums, researchers believe, is a lack of competition. Rural areas are home to fewer doctors, which makes it hard for insurers to score discounts for their policyholders. And rural residents have fewer health insurance options. This year, on average, urban health-care shoppers had their pick of five insurers on the exchanges, the study found; those who live in rural areas had only 3.8 options. Also, urban shoppers were able to choose from one of 17 plans on average, while rural consumers saw an average of 14.2 plan options.

Another problem is that insurance is sold on a state-by-state basis, says Janet Weiner, associate director for health policy at the Leonard Davis Institute of Health Economics. Take Nevada. In a few rural counties bordering Utah and California, there aren’t that many doctors and hospitals, and many of the closest ones are out-of-state. “The insurers do not sell multi-state plans, and so even if there are more providers close by, but across state lines, they cannot expand their provider networks,” Weiner says. “This limits the ability of insurers to drive discounts and keep costs down.”

The potential good news? Rural residents could see some relief in 2015 as more insurers join the exchanges (open enrollment starts on Nov. 15). While some states, including Florida and California, have already announced premium hikes for next year, new insurers could inject some much-needed competition into the marketplaces. For instance, both Cigna and Aetna have announced plans to expand into Georgia, a state where rural customers currently pay 24% more than urban customers do for the same kind of plan. UnitedHealthcare, the nations’ largest insurer, has announced that it will sell policies on far more state exchanges next year. “If insurers see a business opportunity, rural areas may be in luck,” Weiner says.

Read more about the impact of health reform:

 

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.

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.

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