MONEY Health Care

Millions of Obamacare Enrollees Are Missing Out on This Big Savings

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Cost-sharing reductions that lower deductibles are only available to health exchange members with silver plans.

More than 2 million people with coverage on the health insurance exchanges may be missing out on subsidies that could lower their deductibles, copayments and maximum out-of-pocket spending limits, according to a new analysis by Avalere Health.

Those who may be missing out are people with incomes between 100 and 250% of the federal poverty level ($11,770 to $29,425). Under the health law, people at those income levels are eligible for cost-sharing reductions that can substantially reduce their out-of-pocket costs. But there’s a catch: the reductions are only available to people who buy a silver-level plan.

(Cost-sharing reductions are a different type of subsidy than the premium tax credits that are available to people with incomes up to 400% of the poverty level regardless of the type of plan they buy.)

In its analysis of exchange income data for those enrolled in the health insurance marketplaces in 2015, Avalere found that 8.1 million individuals with this coverage had income levels that should have qualified them for cost-sharing reductions. But only 5.9 million received the reductions, which are automatically applied if people enroll in silver-level plans.

Some of those who were eligible probably bought cheaper bronze-level plans, says Elizabeth Carpenter, a vice president at Avalere.

“Surveys show that people shop for plans based on premiums,” Carpenter says. “But if somebody forgoes cost-sharing reductions in order to pay a lower monthly premium and then has an unexpected accident or illness, their out-of-pocket exposure is likely to be higher.”

Silver plans pay 70% of medical costs, on average, while bronze plans pay 60%.

Consumers with a silver plan are thus responsible for paying 30% of their medical costs in deductibles and copayments or coinsurance, up to a maximum of $6,600 for an individual and $13,200 for a family in 2015. Cost-sharing reduction subsidies reduce those out-of-pocket costs. People with incomes that are 150% of the federal poverty level or less are on the hook for no more than 6% of their costs (instead of 30%); those with incomes up to 200% of poverty pay no more than 13%; and those with incomes up to 250% pay 27% at most. Consumers who are eligible for cost-sharing reductions also have lower maximum out-of-pocket spending limits.

In 2015, a standard silver plan has a $2,556 average annual deductible for medical and drug costs for single coverage on the federal exchange, according to a Kaiser Family Foundation analysis. (KHN is an editorially independent program of the foundation.) Cost-sharing reductions would cut the average deductible to $2,077 for someone whose income was between 200 and 250% of poverty, and to $737 for someone whose income was between 150 to 200% of poverty. Someone whose income was 150% of poverty or lower would have a deductible of just $229 for a silver plan.

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

TIME Scott Walker

Scott Walker’s Obamacare Replacement Sounds Familiar

Republican presidential candidate and Wisconsin Gov. Scott Walker speaks to fairgoers during the Iowa State Fair on August 17, 2015 in Des Moines, Iowa.
Justin Sullivan—Getty Images Republican presidential candidate and Wisconsin Gov. Scott Walker speaks to fairgoers during the Iowa State Fair on August 17, 2015 in Des Moines, Iowa.

When Scott Walker launched his campaign for the Republican nomination in July, he said that his first goal would be to repeal Obamacare. On Tuesday, the Wisconsin Governor detailed what he’d do next, and it sounds familiar.

In a speech in the neighboring state of Minnesota, Walker outlined a plan for overhauling America’s healthcare system that draws on the broad principles behind the Affordable Care Act.

There are differences in specifics: the insurance exchanges are now called pools, where small businesses can band together to buy coverage for employees; young adults can stay on their parents’ plans but only if states OK it; and Americans without job-based insurance would qualify for government subsidies based on age instead of income.

And there are some conservative ideas in the mix too: states would run more of the program, insurance regulations would be scaled back or scrapped and medical malpractice lawsuits would be limited.

But overall, the plan reflects a reluctant realization that there are few alternatives to fix many of the problems that Obamacare addressed and that after two Supreme Court decisions, a presidential election and two midterms, the law will be hard to completely upend.

That’s not to say that Walkercare is Obamacare Light.

“On paper, it certainly does provide protections. There are just some holes,” said Larry Levitt, a senior vice president at the non-partisan Kaiser Family Foundation, which has studied the law extensively. If enacted with as little as oversight as outlined, Walker’s plan would likely lead to coverage at levels even lower than pre-Obamacare. “At the talking point level, Governor Walker’s plan sounds an awful lot like Obamacare,” Levitt said. Look a bit deeper, though, and “there are some big differences.”

For instance, the popular prohibition against denying coverage to individuals with chronic conditions such as cancer only is in place if the patient had maintained continuous insurance. Those who let their insurance policies lapse are potentially locked out of private coverage for life. Separately, pricing discrepancies between genders and ages could return. The extremely poor would still have access to health coverage, although it would not meet the current standards. There are no limits to out-of-pocket health costs, although Walker would allow Americans to set aside more money for their own health care tax-free.

Yet Walker includes some of Obamacare’s most popular provisions, such as guaranteeing access to health insurance to all Americans. “In the very broad brushstrokes, that’s also what Governor Walker’s plan does. The similarities end there,” said Topher Spiro, a former Capitol Hill senior aide who helped lawmakers write Obamacare.

For instance, older and poorer Americans would be treated less fairly under Walkercare than under Obamacare. Tax credits would be even for all Americans, regardless of income; that benefits wealthier Americans who don’t need the help. “If you’re making $150,000, you’re getting the tax credit. It’s not very efficient. It’s very wasteful,” said Spiro, now at the liberal Center for American Progress.

Democrats were fast to criticize the proposal. “Thanks to the Affordable Care Act, 16 million Americans have gained health insurance, the uninsured rate is at its lowest point ever recorded, health spending grew at the slowest rate in 50 years, all while we’ve had 65 months of consecutive private sector job growth,” Democratic National Committee spokesman Eric Walker said. “This law saves money and lives, but Republicans’ only plan is repeal.”

The plan also drew criticism from one conservative rival. Louisiana Governor Bobby Jindal, badly trailing in the polls, called Walker’s subsidies a “new entitlement program.” “It is frankly shocking that a Republican candidate for President would author a cradle-to-grave plan like this,” Jindal said in Iowa.

Perhaps most problematic, however, is that Walker’s plan ignores the political realities. Repealing Obamacare requires votes from both chambers of Congress and a President’s signature. Under the current rules, it would take 60 votes in the Senate to get past a key procedural hurdle. Republicans currently only have 54 Senators and the 2016 map is no cakewalk for the GOP.

Then, there is the actual legislating. Walker’s replacement plan would require states to pick up the slack, but state Legislatures do not meet year-round and there’s no guarantee that even Republican-led statehouses would rush to set up a healthcare system based on Washington’s offers.

“If the federal government put the responsibility for regulating insurance and creating new programs back on the states, it would take time to put those in place. Every state Legislature would have to go through a debate about what kinds of rules they wanted in the insurance market,” Levitt said. “We’re talking about several years, even if the law based on this plan were to pass.”

Walker’s plan also is likely to face opposition from the healthcare industry. After years of preparation and adjustments to comply with Obamacare, yet another fundamental shift is hardly one they—and their shareholders—are going to embrace. Most rewrote policies to comply with the new mandates.

Then, there are the actual consumers. The Urban Institute estimated that roughly 2.6 million Americans had to switch health plans to shift onto Obamacare-compliant policies. In many cases, they were most costly but also more comprehensive. A few consumers would want cheaper plans, but fewer would want to go back to plans that lacked serious coverage or protections. Asking Americans to give up existing benefits, whether it is a prescription plan or Social Security, is never a political winner.

Half of Americans disapprove of the Affordable Care Act, while only 44 percent approve, according to the most recent Gallup survey. But there’s a big distance between disliking a law and agreeing on what should replace it.

MONEY politics

Kasich Says Obamacare Empties Prisons—In a Good Way

The Ohio governor says the program, unpopular with Republicans, has reduced recidivism rates.

Ohio Gov. John Kasich defended his expansion of Medicaid under Obamacare at Thursday night’s Republican presidential debate.

The Medicaid expansion, unpopular among many of the Republican faithful, has benefited mentally ill prison inmates, said Kasich.

“I’d rather get them their medication so they could lead a decent life,” he said.

“Eighty percent of the people in our prisons have addictions or problems,” Kasich added. “We now treat them in the prisons, release them in the community and the recidivism rate is 10 percent….”

Participants in the debate, held in Cleveland and televised on Fox News, were Kasich, former Arkansas Gov. Mike Huckabee, retired neurosurgeon Ben Carson, New Jersey Gov. Chris Christie, real estate mogul Donald Trump, former Florida Gov. Jeb Bush, Wisconsin Gov. Scott Walker, Florida Sen. Marco Rubio, Kentucky Sen. Rand Paul, Texas Sen. Ted Cruz.

MONEY

Think Health Care is Pricey? Get Ready to Spend Even More

pile of prescription medicine pills and tablets
Jan Mika—Shutterstock

Soon one out of every five dollars Americans spend will to go healthcare.

For the past six years Americans have gotten a respite from fast-rising health care costs. No more.

With millions of baby boomers entering retirement and pricey new drugs hitting the market, U.S. health care spending, which had increased at relatively moderate 4% rate since the financial crisis, grew 5.5% last year, according to a new government study reported on Tuesday by The Wall Street Journal.

You can expect more too. The actuaries who calculated the figures, project that spending will average 5.8% between 2014 and 2024. By then, health care as a share of the nation’s overall economy will have grown to 19.4% from 17.4% in 2013. In other words, our nation’s medical bills will account for one out of every five dollars we spend.

The changes aren’t totally unexpected. A big part of the extra costs are tied to the fact that baby boomers — many now in their 60s — are requiring more care. Important but expensive new drugs, like one that helps treat Hepatitis C, are also a factor, according the Journal.

Still, the rising costs aren’t good news, especially considering a key promise of the Affordable Care Act, which brought access to health insurance to millions of Americans, was to get the growth in health care spending under control, a goal known as “bending the curve.”

For people who get their health insurance coverage at work, rising costs are likely to mean a continued push by employers toward high-deductible plans, which can have steep out-of-pocket costs. Read here for more on tools for keeping medical bills under control.

TIME john kasich

Hillary Clinton Dined With John Kasich Over Healthcare Reform—In 1993

Republican U.S. presidential candidate and Ohio Governor John Kasich formally announces his campaign for the 2016 Republican presidential nomination during a kickoff rally in Columbus
Aaron Bernstein—Reuters Republican presidential candidate and Ohio Governor John Kasich formally announces his campaign for the 2016 Republican presidential nomination.

A decades old meeting between two 2016 rivals takes on new significance.

Just months after her husband took office, First Lady Hillary Clinton attended an unusual backyard dinner in Northern Virginia on her quest to sell the healthcare reform plan known as Hillarycare.

The June 1993 gathering was at the home of then-House Budget Committee ranking member John Kasich, the same man who announced his campaign as a 2016 presidential candidate for a Republican Party still furious about a healthcare reform bill by President Obama that drew heavily on the work of Clinton from the early 1990s.

At the time, Kasich was developing his own national health insurance proposal, which offered a more marketplace-based solution than what emerged in Obamacare. The Kasich plan would have covered all Americans by 2005, using a form of an individual mandate that would have required employees to purchase insurance through their employers. (The mandate was an idea initially supported by conservative groups like the Heritage Foundation.)

In his announcement speech this week, Kasich referred to his work on health issues in the 1990s. “I went on to chair the Health Committee where I learned to work across the aisle because the House was run by Democrats,” Kasich said of his time working in the State Senate. “And that’s where I learned that policy is far more important than politics, ideology, or any of the other nonsense we see.”

In 1993, the bipartisan outreach included the dinner with Clinton and nine fellow Republicans. Afterwards, Kasich declared Clinton had been “a big hit,” with the crowd.

A contemporaneous memo released last year by the Clinton Library provides more insight into the meeting, and Kasich’s role in the healthcare reform effort.

After the dinner, “Congressman Kaslch, has been quite complimentary about you, personally, and the Administration’s consultative and outreach process for health reform,” Clinton aide Chris Jennings wrote to Hillary Clinton in a memo.

Before a follow-up meeting two weeks after the dinner, Jennings pegged Kasich as a strong target for administration outreach. “Kasich, given his reputation as a smart and serious legislator, can be very helpful With mainstream Republicans,” Jennings wrote. “In addition, he seems to have gained the respect of the media so his supportive comments about you and the process can have a positive impact externally on public perception, as well.”

“Even if he ultimately opposes the plan,” Jennings concluded, “his positive feeling toward you and the process may mute his criticism and moderate the Republican opposition effort.”

In 1993, before the Clinton meetings, Kasich released a report on healthcare that amounted to a “rather stereotypical conservative position on health reform,” in Jennings’ words, including means-testing Medicare, increasing co-payments, and using private healthcare savings accounts. But, he added, “it also includes a number of suggestions that are consistent with the direction the Administration has been heading including: Developing incentives for greater use of competition in the Medicare and Medicaid programs, providing flexibility/waiver authority to the states, reducing health care fraud, assuring Insurance portability, establishing purchasing groups, and addressing the medical liability problem.”

A year later, Kasich introduced a plan that would have provided health insurance to all Americans by 2005, requiring them to purchase insurance through their employers on the private market, with government subsidies helping those below or near the federal poverty line. Small businesses and individuals would have been able to join “voluntary alliances” to purchase insurance as a pool. It also ensured that those with pre-existing conditions could get coverage.

Kasich aides said the meeting with Clinton is an example of his willingness to create connections with all sides, including those he disagrees with. “They certainly didn’t agree, but that didn’t keep him from wanting them to engage in converation,” said Kasich spokesman Scott Milburn.

Ultimately, Hillary Clinton’s effort was doomed to failure—though some of its proposals found a home later in the Affordable Care Act.

Many of Kasich’s own ideas for the era were gathered into the Affordable Care Act as well, though Kasich takes issue with their implementation. He has long called for ensuring that all Americans have health care insurance, but, in line with his party’s thinking about the healthcare law, has said he would sign a repeal of the bill.

“He wants to see people cared for, and he wants a competitive free market approach to do it,” Milburn said.

Aides point to Kasich’s turn to expanding managed care healthcare plans in Ohio, which has halved the rate of cost growth, as an example of the types of reforms he is looking to expand nationally.

Kasich frequently defends his decision to expand Medicaid on the campaign trail, tying it to his broader message of compassionate conservatism, arguing that those facing drug addiction, mental illness, and other difficulties should be cared for.

“I’m not for Obamacare.” Kasich told Bloomberg in April. “I have expanded Medicaid, because I wanted to bring Ohio dollars back to Ohio. We’ve been able to apply it to bring significant change, and our ultimate goal is that so all of these people who have been hurt can be in a position to get on their feet and move forward.”

TIME Congress

13 Reasons the Government Could Shut Down Again This Fall

Congress Convenes On Columbus Day As Government Shutdown Continues
Mark Wilson—Getty Images The U.S. Capitol in Washington in 2013.

Democrats and Republicans don't see eye to eye on spending

Do you miss the government shutdown? Don’t worry, another one could be coming as soon as this fall.

You might have thought the threat of another shutdown was shelved last year when congressional Budget Committee Chairs Rep. Paul Ryan and Sen. Patty Murray came to a two-year bipartisan deal to fund the government.

But the new Republican Congress blew up that deal, and a shutdown could be part of the fallout.

Republicans are now attempting to undo controversial cuts to military spending in the 2013 sequester. Democrats are having none of that: if the Pentagon gets its money, they argue, so too should entitlements, as was part of the original deal. Unless Republicans relent on this point, Democrats have vowed to block all 13 appropriations bills from coming to the Senate floor.

But even if those bills were to get voted on, odds are they won’t pass since they have dozens of provisions that Democrats object to — and which President Obama has threatened to veto.

If some sort of funding isn’t passed by the end of September, the government will shut down. Senate Majority Leader Mitch McConnell swears that will not happen on his watch, but for now the two sides aren’t even talking.

So what could cause a shutdown? Here’s a look at the 13 most controversial provisions, any one of which could trigger a partial or total government shutdown if Democrats and Republicans can’t come to an agreement.

  1. Obamacare: Of course, the bills cut funding for the implementation of Obamacare — the same law that caused the last shutdown.
  2. The environment: The bills would essentially defund or block the President’s climate change plan—including his recently issued controversial rule for coal fired power plants, a clean water rule and a bunch of endangered species listings. All told there are more than 30 riders that environmental groups are protesting.
  3. Cybersecurity: On the heels of a massive breach of personal information for tens of millions of government employees, the GOP budgets would delay installation of cybersecurity upgrades to federal agencies to protect against foreign attacks and cut funding to protect the nation’s electronic grid from cyber attacks and extreme weather by 40%.
  4. Education: The GOP bills would cut nearly $6 billion in education funding, eliminating six pre-K-12 programs, slashing Head Start by $1.5 billion, cutting 21st Century Community Learning Centers by 10% and School Improvement Grants by 11% and $300 million in Pell Grants.
  5. Labor: As the President negotiates two of the largest free trade pacts in the world, he has pledged to ensure that they will meet fair labor standards and not empower countries to abuse their workforces. But the enforcement of these provisions falls on a Labor Department office, the same office that Republicans are looking to cut by 67%. Also on the chopping block: 5% of the Occupational Safety and Health Administration’s budget and 8% of the budget of the office that protects workers from wage theft and abuse.
  6. Veterans: Despite the ongoing scandal plaguing the Veterans Affairs Administration, the budgets cut $255 million from veterans medical care and $105 million from maintenance for VA hospitals.
  7. Consumer protection: The GOP bills would cut $200 million in funds to implement Wall Street re-regulation, or the Dodd-Frank bill passed in the wake of the financial crisis to prevent something like that from happening again. And it attempts to defund Sen. Elizabeth Warren’s darling, the Consumer Financial Protection Bureau, which was set up in the wake of the crisis to better protect Main Street from the risks Wall Street is taking.
  8. Women’s health: The bills cut funding for Title X family planning service programs, eliminating access to birth control for the 4.7 million clients that the programs served in 2012, preventing an estimated 1.2 million unintended pregnancies. They also slash funding to prevent teen pregnancies by 81%.
  9. Infrastructure: In the wake of a fire in a Chicago radar facility that knee capped Midwest air traffic for weeks as air traffic controllers tracked planes with pen and paper, the Transportation Department asked for more money for air traffic control. Instead, Republicans are seeking to cut $255 million from the air traffic control system. Other targets include: $479 million in cuts to water infrastructure $400 million in cuts to innovation grants and $1.7 billion in cuts to transit projects across the country.
  10. Job training: The bills propose cutting $650 million from job training programs.
  11. Wildfires and disease: The GOP budgets envision cutting $1 billion from funding to fight wildfires. Also on the chopping block: $500 million for the Agriculture Department to research diseases like the avian flu.
  12. National parks and national service: The bills cut the National Park Services budget by $321 million, despite the fact that the agency has a massive $11 billion backlog. It also cuts $340 million, or 29%, from AmeriCorps, which translates into 32,000 fewer members serving their communities.
  13. Health: The GOP budgets propose cutting lead paint removal in low-income households, potentially putting more than 2,000 children at risk. And they cut funding for 9,000 scientists’ research at the National Science Foundation.

TIME Healthcare

Birth-Control Costs Nearly Halved After Obamacare, Study Finds

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

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

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

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

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

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

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

TIME Uber

Why the Obamacare Decision Is Great for Uber

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

The gig economy should be celebrating this week

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

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

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

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

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

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

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

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

This article originally appeared on Fortune.com.

MONEY Health Care

Obamacare Still Has 5 Key Hurdles to Clear

150626_FF_ObamacareHurdles
Peter Dazeley—Getty Images

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

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

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

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

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

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

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

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

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

TIME society

Obamacare Victory Shows Failure of Scalia’s Conservative Revolution

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

This is clearly not the Scalia Court

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This article originally appeared on The ConversationThe Conversation

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

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