Welcome to Health Reform Watch, Jason Millman's regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Jason with questions, comments and suggestions here. Check back every Tuesday and Thursday afternoon for the latest edition, or sign up here to receive it straight from your inbox. Read previous columns here.
It's been two weeks since a pair of federal appellate courts issued split rulings on whether Obamacare actually authorizes the 36 states relying on federal-run health insurance exchanges to provide premium subsidies helping low- and middle-income residents purchase coverage. If the legal argument pushed by critics of the law ultimately prevails, it could pretty much up-end the exchanges in states that have deferred responsibility to the federal government.
The cases center on whether the Affordable Care Act specifically provides subsidies in the federal-run exchanges or if Congress meant to withhold assistance in federal-run exchanges to incentivize states to run their own health insurance marketplaces. The split ruling from appellate courts in the District of Columbia and Virginia have spurred no shortage of commentary on the court cases and reviews of legislative history. Meanwhile, new polling shared first with Wonkblog provides insight into how the public views these cases — Halbig v. Burwell and King v. Burwell.
In short: People haven't paid that close attention to these challenges to Obamacare, and they don't totally understand them. But they mostly agree that anyone eligible for a subsidy should be able to receive it, regardless of who's running an exchange.
The new Morning Consult poll of about 1,800 registered voters found that 58 percent of those surveyed said all exchanges — whether they're state- or federal-run — should provide subsidies, while 15 percent disagreed and 27 percent didn't offer an opinion. As the below chart shows, those identifying as liberal were more likely to support subsidies in any exchange (74 percent), although those identifying as conservative were twice as likely to support subsidies through all exchanges (47 percent versus 24 percent).
People responding to the Morning Consult survey were asked: "Do you think people purchasing health insurance should have access to subsidies if they meet all other qualifications, regardless of whether the exchange was set up by the states or by the federal government?"
Before that, people were asked whether the subsidy confusion was the result of a drafting error or if Congress intentionally wrote the law only to allow subsidies through state-run exchanges. There was significant confusion on this question: 22 percent of registered voters said it was a drafting error; 25 percent said Congress meant to limit subsidies; and 54 percent said they had no opinion or they didn't know. There was a partisan split on this question (39 percent of liberals said it was a drafting error, compared to 15 percent of conservatives), but no majority position for either group.
Further, these lawsuits haven't gotten that much attention. Just 14 percent of all registered voters said they paid "a lot" of attention to these cases, 30 percent said "some," 29 percent said "not much" and 28 percent said "not at all."
A note about the methodology: it's drawn from a survey of opt-in online panelists, which cannot be confidently generalized to the U.S. population of registered voters.
These subsidy lawsuits could eventually wind up before the Supreme Court. The Obama administration has asked the entire D.C. Circuit to re-hear the case after a three-member panel ruled the subsidies illegal. Obamacare opponents who lost their case in the Virginia appellate court have asked the Supreme Court to take their lawsuit.
Should the courts ultimately decide against the Obama administration, there is a pretty easy fix in theory, as the Huffington Post's Jeffrey Young points out. There's nothing preventing Congress, aside from the GOP's staunch opposition to the law, from passing additional legislation making clear that all exchanges could provide premium subsidies. It seems, at least from this latest poll, the public would support that.
Top health policy reads from around the Web:
States that like Obamacare have done better insuring their residents. "Some states that expanded Medicaid under the Affordable Care Act and set up all or part of their own insurance exchanges have seen a marked drop in the number of uninsured adults. The uninsured rates in states that opted to expand Medicaid, a health program primarily for low-income residents, and set up their own exchanges declined more in the first half of 2014 than in the states that didn’t take that approach, according to a study released Tuesday by Gallup. The uninsured rate declined 4 points in the 21 states that expanded Medicaid and set up their own exchange, compared with a 2.2-point drop across the 29 states that implemented only one or neither of those steps." Stephanie Armour in the Wall Street Journal.
This part of HealthCare.gov is working pretty well. "The IRS generally is reporting accurate income and family size information to the Obamacare’s new insurance exchanges, according to a Treasury audit Tuesday that offers good news to an Obama administration dogged by questions about whether its health care law’s systems actually work. The inspector’s review looked at more than 100,000 information requests between Oct. 1 and Oct. 4, the first four days that Obamacare exchanges were open for enrollment, and found the IRS’s responses were 99.7 percent accurate. The requests are vital to determining whether a person is eligible for coverage on the exchange and may receive government subsidies to knock down the cost of coverage." Tom Howell Jr. in the Washington Times.
What happens when health prices are transparent. "[The] lack of transparency in health prices partially explains why there is huge variation in what doctors charge for the exact same service. An appendectomy can cost anywhere between $15,000 and $186,000. Doctors don't usually feel the need to make their prices competitors when shoppers can't see them. Over the past two years the Blue Cross and Blue Shield health plans have been running a quiet experiment, to see what would happen if prices became available in some cities but not others. And they found that just the act of making prices available can have a really dramatic impact on what they had to spend to get patients a very basic procedure." Sarah Kliff in Vox.