Patient Protection and Affordable Care Act

Montana Governor Steve Bullock, a Democrat, has asked legislators once again to expand health coverage for 70,000 low-income Montanans, the Independent Record reports: "Legislative Republicans rejected a Medicaid-expansion proposal in 2013, arguing the state couldn’t afford it and that they didn’t want to implement part of 'Obamacare,' the 2010 federal health-care law. Bullock ... said his new plan is a unique proposal for expanding Medicaid. It would use federal money to contract with a private administrator to process claims and run a network of physicians, hospitals and other providers to serve the newly covered population, he said."

The costs of health-insurance policies bought under the Affordable Care are projected to go up in 2015--even as much as 20 percent, the New York Times reports. The solution? Switching plans: "The new data means that many of the seven million people who have bought insurance through federal and state exchanges will have to change to different health plans if they want to avoid paying more — an inconvenience for consumers just becoming accustomed to their coverage."

The U.S. Supreme Court has taken up another existential challenge to Obamacare. The plaintiffs in King v. Burwell allege that the Affordable Care Act doesn't allow the federal government to provide tax credits and subsidies to low-income and moderate-income consumers shopping for insurance on the federally-run insurance exchange, The Huffington Post's Jeffrey Young reports. The Obama administration argues that Congress intended to provide tax credits to people shopping for health insurance whether an exchange is state-run or federally run, but the plaintiffs allege the Affordable Care Act only allows subsidies for insurance bought on an "'exchange established by the state,'" Young also reports.

If the Supreme Court rules in favor of the plaintiffs, "absent financial assistance, many fewer people would be able to afford coverage and likely would drop their insurance or never purchase it. Higher prices also would discourage healthy people who are cheaper to insure from buying policies, leaving a sicker pool of customers on insurers' books," Young further reports.

Jason Millman, writing in the Washington Post's Wonkblog, says that the Republican victory in several gubernatorial races means that Medicaid expansion under Obamacare may not happen in several states: "Fifteen of the 23 states that hadn't yet expanded Medicaid held gubernatorial elections last night, and it looks like only Alaska will elect a candidate who campaigned for the Medicaid expansion." There might even be a real chance of undoing Medicaid expansion in Arkansas.

But Millman also notes that several Republican governors have said they might explore expanding their Medicaid coverage and "Medicaid expansion has support from hospitals, which hold considerable political clout and have a lot to lose without the infusion of federal funds from the expansion."

Companies are going to face fines next year if they don't comply with a mandate to provide health insurance to employees. In order to avoid $2,000 penalties per employee, some companies are trying to enroll low-wage employees in Medicaid or to offer "skinny" plans that cover preventive care but exclude major benefits like hospital coverage, the Wall Street Journal reports. Employers, however, can face a different $3,000 fine for workers who opt out of the "skinny plans" and get federally subsidized plans through an insurance exchange. Other employers are reducing the number of workers who are eligible by keeping their hours below 30 a week.

Adam Liptak, writing in the New York Times, prognosticates that this term of the U.S. Supreme Court could define Chief Justice John Roberts Jr.'s legacy with possible cases about whether gay Americans have a constitutional right to marry and about federal subsidies to consumers who purchase health-care coverage through federally run insurance exchanges. "Chief Justice John G. Roberts Jr. is entering his 10th term, and it is one that could define the legacy of the court he leads. Should the court establish a right to same-sex marriage, it would draw comparisons to the famously liberal court led by Chief Justice Earl Warren, said David A. Strauss, a law professor at the University of Chicago," Liptak reports. The justices have not decided whether to take up cases involving same-sex marriage or Obamacare yet.

Laurie Garrett, writing in Foreign Policy, has an interesting an piece suggesting that Obamacare may be the key to stopping an Ebola epidemic in the United States. She notes that uninsured Americans are the "greatest vulnerability" because they "routinely tough out the flu, fever, aches, and pains because seeking medical care is prohibitively expensive. If they become sick enough to feel desperate, the uninsured and underinsured of America go to public hospital emergency rooms for care, where waiting times in often-crowded settings can stretch on for hours." No one suffering from the primary symptoms of Ebola should be turned away from care because they lack insurance, she says.

The U.S. Supreme Court is facing a circuit split on whether the federal government can provide tax subsidies to low-income workers to obtain health insurance on the federally-run insurance exchanges, SCOTUSBlog's Lyle Denniston reports. The U.S. Court of Appeals for the D.C. Circuit has said no (but the en banc court is going to hear the case in December). The Fourth Circuit has said yes. U.S. District Judge Ronald A. White, who sits in Oklahoma, added to the list of 'no' rulings yesterday.

According to the New York Times, White's ruling appears to increase the likelihood that the Supreme Court will resolve the issue. SCOTUSBlog's Denniston reports that White "relied on what he found to be the clear language of the ACA on that point — that is, subsidies are only to be available on an exchange 'established by the state.'  It was not his option, the judge said, to read the entire health care law to find reasons to make sure that the subsidy system worked in all exchanges across the country, federal and state."

The Washington Post reports that the millions of of enrollees who have benefited from the expansion of Medicaid appear to be "generally happy to have coverage, though many are encountering roadblocks to receiving the care they want, according to new research that provides one of the earliest insights into people's experiences under the expanded health insurance program for low-income Americans." The biggest problem for enrollees has been finding a primary care doctor, the Post further reports, because many doctors won't take new Medicaid patients.

In a separate report, the Los Angeles Times reports that as many as 500,000 people, or 10 percent, who have signed up for coverage under the Affordable Care Act may lose coverage or need to pay more because they haven't verified their citizenship or immigration status, or sent in the forms proving their income. The downside? "The Obama administration may face a backlash from consumers who will be asked to repay hundreds or thousands of dollars in subsidies that they weren't entitled to receive," the Times further reports.

There's another glitch in Obamacare, according to a Washington Post report: "A flaw in the federal calculator for certifying that insurance meets the health-care law’s toughest standard is leading dozens of large employers to offer plans that lack basic benefits, such as hospitalization coverage, according to brokers and consultants." The calculator is mainly used by self-insured employers and will allow employers to avoid getting fined as much as $3,000 per worker next year.