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 Medicaid

Medicaid Enrollment Surge Causes Concern About State Budgets

obamacare health care affordable
Lucy Nicholson—Reuters Arminda Murillo, 54, reads a leaflet at a health insurance enrollment event in Cudahy, Calif. on March 27, 2014.

Lawmakers warn that the price of expanding could mean less money for other state services

ATLANTA — More than a dozen states that opted to expand Medicaid under the Affordable Care Act have seen enrollments surge way beyond projections, raising concerns that the added costs will strain their budgets when federal aid is scaled back starting in two years.

Some lawmakers warn the price of expanding the health care program for poor and lower-income Americans could mean less money available for other state services, including education.

In Kentucky, for example, enrollments during the 2014 fiscal year were more than double the number projected, with almost 311,000 newly eligible residents signing up. That’s greater than what was initially predicted through 2021. As a result, the state revised its Medicaid cost estimate from $33 million to $74 million for the 2017 fiscal year. By 2021, those costs could climb to a projected $363 million.

“That is a monstrous hole that we have got to figure out how to plug, and we don’t know how to do it,” said Kentucky state Sen. Chris McDaniel, a Republican who leads the Senate budget committee and opposed expansion. “The two biggest things that keep me up at night are state pensions and the cost of expanded Medicaid.”

For patients who have only recently gained access to health care, the program is about far more than dollars and cents. And supporters downplay the budget concerns, pointing to studies that indicate the economic benefits of expanding health care will result in significant savings over time.

Several expansion states have already revised their budget estimates due to the larger than expected enrollments, according to an Associated Press review.

McDaniel said the added Medicaid costs will reduce the pool of money that can be invested in higher education, pension plans or other services.

Supporters of the expansion, including Kentucky Gov. Steve Beshear, predict their states will save money in the long run because Medicaid will allow some state-run services to be eliminated and will stimulate the economy through new revenues and job creation. Beshear, a Democrat, released a study earlier this year touting the creation of 12,000 jobs and nearly $1.2 billion in new revenue to health care providers as a result of expansion.

Thirty states and the District of Columbia have expanded Medicaid, or plan to do so, to include all adults with incomes at or below 138 percent of the federal poverty level, currently $16,243 for an individual.

The federal government agreed to pay all costs for the new enrollees through 2016, but it will begin lowering its share in 2017. States will pay 10 percent of the costs by 2020.

In the expansion states, enrollment for Medicaid and a related program for children have increased an overall 28.2 percent compared with a three-month period before the law’s implementation, according to the federal government. In a recent report, economic experts at the U.S. Department of Health and Human Services said they expect estimated enrollment and per-person cost increases to level off and even decline over the long run.

At least 14 states have seen new enrollments exceed their original projections, causing at least seven to increase their cost estimates for 2017, according to an Associated Press analysis of state budget projections, Medicaid enrollments and cost details in the expansion states. A few states said they could not provide original projections.

California has enrolled nearly 2.3 million people so far — almost three times more than the 800,257 the state had anticipated. Enrollment in neighboring Washington more than doubled. Oregon’s new enrollments have exceeded estimates by 73 percent.

In Michigan, estimated costs have shot up by 50 percent because of soaring enrollment. Ohio’s projected costs more than doubled.

Some states that expanded their Medicaid programs prior to the federal health care law are also seeing enrollment increases based on people signing up because of increased publicity and outreach efforts.

In states where ongoing discussions over Medicaid expansion have yet to be resolved, opponents are quick to cite the surging enrollments and costs. Last month, Republicans in the Florida House repeatedly warned about the costs before soundly defeating an expansion bill.

“Every piece of metrics and data we have seen has showed the Medicaid rolls have exploded,” said state Rep. Blaise Ingoglia. “And it’s putting taxpayers and future prosperity at risk.”

Health care already consumes a large portion of state spending each year, second only to K-12 education. It now represents more than half of all federal funds received by states, according to the National Association of State Budget Officers.

The very nature of Medicaid — that enrollments typically increase in tough economic times — means states must be strong enough financially to continue supporting the expanded program even in future downturns.

An Associated Press review earlier this year found at least 22 states were dealing with budget shortfalls for the 2016 fiscal year.

“In those states that do have budgetary balance, it’s somewhat tenuous,” said credit analyst Gabriel Petek with Standard & Poor’s Ratings Services. Add the cost of rising Medicaid enrollments and “something has to give. Most likely, it means they have to spend less in other areas or they have to increase their tax revenues.”

Oregon originally estimated 222,700 newly eligible Medicaid recipients would sign up by the end of June, but that number ballooned to 386,000.

Paying for the new enrollees isn’t the only Medicaid cost troubling Oregon lawmakers. Starting in 2017, the state loses $1.9 billion in federal aid that has propped up the Medicaid program since 2012 under a special deal with the government.

Between the Medicaid expansion, the lost federal aid and normal growth, Oregon’s Medicaid budget is expected to need $500 million between 2017 and 2019, said Democratic state Sen. Richard Devlin, one of two lawmakers who oversee the budget.

The best solution, he said, is to make sure people are working and don’t need the government health care program.

“I think, really, the only way to keep this manageable is to keep those costs under control, get people off Medicaid,” he said.

For those who were able to sign up for Medicaid when their states expanded eligibility, the program has offered big quality-of-life improvements.

Among them is Earl Charles Williams Sr., a 59-year-old part-time social worker in Chicago. He said he can only imagine what life would be like without the free care he now receives.

His diabetes under control, Williams said his doctor makes sure he comes to the office every few months and keeps him on a healthy regimen.

“There are so many people who really need the care,” he said. “They have nothing. And when they have nothing, you can see the effect on the community.”

Supporters of expanding Medicaid say states will eventually save money by doing away with some of their own services for the uninsured, such as mental and behavioral health programs, and by reducing payments to hospitals and other providers for treatment of the uninsured.

Kentucky saved $9 million in 2014 as enrollees in behavioral and mental health programs were fully covered by Medicaid, according to a report by the State Health Reform Assistance Network, a program of the Robert Wood Johnson Foundation. Some states, including West Virginia and Arkansas, are reporting costs are lower than expected.

Elsewhere, there are signs that some of the hoped-for savings might not be realized quickly.

In New Mexico, where enrollment under the Medicaid expansion surpassed projections by 44 percent, legislative analysts warned last month that the state will not save as much money as originally projected because cost-containing measures have proven difficult to implement.

In addition, legislative staff said New Mexico lawmakers will have to consider taking money from other state agencies to fill the gap.

“When you’re looking at a state budget and there are only so many dollars to go around, obviously it’s a concern,” said state Sen. Howie Morales, a Democrat who sits on the powerful Legislative Finance Committee. “The most vulnerable of our citizens — the children, our senior citizens, our veterans, individuals with disabilities — I get concerned that those could be areas that get hit.”

Associated Press writers Adam Beam in Frankfort, Kentucky; Susan Montoya Bryan in Albuquerque, New Mexico; Jonathan J. Cooper in Salem, Oregon; Carla K. Johnson in Chicago; Kelli Kennedy in Miami; Judy Lin in Sacramento, California; and Gosia Wozniacka in Portland, Oregon, contributed to this report.

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 health

Obamacare Allows Phony Applicants to Automatically Re-Enroll in Program

Obamacare Health Insurance Marketpalce
Jon Elswick—AP File photo dated Oct. 1, 2013 of application and instructions paper work for the Affordable Care Act.

Investigators from the Government Accountability Office had set up fake applications in 2014

(WASHINGTON) — Phony applicants that investigators signed up last year under President Barack Obama’s health care law got automatically re-enrolled for 2015. Some were rewarded with even bigger taxpayer subsidies for their insurance premiums, a congressional probe has found.

The nonpartisan Government Accountability Office says 11 counterfeit characters that its investigators created last year were automatically re-enrolled by HealthCare.gov. In Obama’s terms, they got to keep the coverage they had.

Six of those later were flagged and sent termination notices. But GAO said it was able to get five of them reinstated, by calling HealthCare.gov’s consumer service center. The five even got their monthly subsidies bumped up a bit, although GAO did not ask for it. The case of the sixth fake enrollee was under review.

HealthCare.gov does not appear to be set up to detect fraud, GAO audits and investigations chief Seto Bagdoyan said in prepared testimony for a Senate Finance Committee hearing Thursday. A copy was provided to The Associated Press.

HealthCare.gov’s document-processing contractor “is not required to seek to detect fraud,” said Bagdoyan. “The contractor personnel involved in the document-verification process are not trained as fraud experts and do not perform antifraud duties.”

Administration officials told GAO there has been “no indication of a meaningful level of fraud” in the program, Bagdoyan said.

Federal health care subsidies go directly to insurers, so the money does not end up in the bank accounts of individual enrollees. But health insurance is a valuable product in and of itself, with the cost of family coverage averaging close to $17,000 a year.

Finance Committee chairman Orrin Hatch, R-Utah, said the GAO’s investigation reveals “negligence” by the Obama administration, which “calls into question the legitimacy of the health law’s enrollment numbers and challenges the integrity of the website’s security checks.”

Last year, when GAO first disclosed that it had succeeded in signing up fake beneficiaries, the administration said it would work to strengthen HealthCare.gov’s verification checks. Administration officials had no initial comment Wednesday on GAO’s latest findings.

HealthCare.gov is an online insurance marketplace used by residents of 37 states to get subsidized private coverage under the health care law.

Although the administration has terminated coverage for more than 200,000 people who could not prove their citizenship or legal immigrant status, and some 300,000 have had their subsidies changed because of discrepancies over reported income, GAO’s bogus beneficiaries largely evaded that dragnet.

It’s unclear whether the fictitious enrollees would have been kicked out of the program eventually. For example, no tax returns were filed on behalf of any of them. Since health insurance subsidies are income-based, tax returns are one of the main ways the government checks applicants.

GAO’s investigation also uncovered a problem that bedevils millions of real people dealing with the program’s new bureaucracy: confusing and inaccurate communication.

Investigators said their bogus enrollees received unclear correspondence that failed to identify the problems with their applications.

“Rather than stating a message directly, correspondence instead was conditional or nonspecific, stating the applicant may be affected by something, and then leaving it to the applicant to parse through details to see if they were indeed affected,” said Bagdoyan.

The fake enrollees also got some perplexing instructions from HealthCare.gov. Eight of the 11 were asked to submit additional documentation to prove their citizenship and identity. But the list of suitable paperwork detailed documents for verifying income instead.

About 10 million are getting coverage this year through HealthCare.gov and state health insurance markets. GAO said the results of its undercover testing, while illustrative, cannot be generalized to the full population of applicants and enrollees.

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.

MONEY Health Care

What is Obamacare?

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

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

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

How does the law help people get insurance?

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

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

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

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

What does coverage cost?

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

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

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

What kind of coverage can I get?

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

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

How is all this paid for?

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

Why are some people fined for not buying coverage?

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

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

MONEY Health Care

Here is How Much the Government Will Pay to Help You Buy Obamacare

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The Supreme Court decided that health care subsidies should remain available to everyone who buys Obamacare plans

Today the Supreme Court decided that Americans who buy health insurance on Healthcare.gov are eligible for subsidies to help them pay their premiums.

The decision shines a bright light on the oft-forgotten linchpin that holds the sweeping 2010 health care law together: The federal government is handing people significant amounts of money to pay their premiums.

Under the Affordable Care Act, popularly known as Obamacare, those who don’t have health insurance can buy plans on government-run marketplaces or “exchanges.” States may either set up their own marketplaces or opt to use the federal government’s marketplace, available on Healthcare.gov. Then, the government provides subsidies to help people afford the healthcare premiums.

The court case was about whether the law said the subsidies applied in states that didn’t set up their own exchanges. (The argument was over how to read one clause in the legislation.) The Supreme Court decided that health care subsidies should remain available to everyone who buys Obamacare plans.

The subsidies make a huge difference to the people who receive them: On the federal exchange, they’re worth an average of $272 a month.

Use this calculator from the Kaiser Family Foundation to see how much an Obamacare plan would cost you, and how much is covered by the subsidies:

And a lot of people qualify: 87% of people who bought Obamacare plans on the federal exchange got a subsidy. Anyone who makes up to 400% of the poverty line is eligible. In 2015, families of four that earned $95,400 made the cutoff.

Policymakers will continue to debate whether the subsidies are accomplishing the goal of making health care affordable. The Government Accountability Office recently found that subsidies “likely contributed to an expansion of health insurance coverage in 2014.” But it’s not like health insurance premiums are cheap, even with financial assistance from the government. After all, Americans who get health insurance at work pay less, on average: $90 a month for single coverage, according to the Kaiser Family Foundation. That’s up from just $27 a month 15 years ago.

And by the way, workplace coverage is (indirectly) subsidized by the government too, in the form of a tax break that makes it very attractive for companies to offer.

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