By Cathryn Domrose
UPDATE: The U.S. Supreme Court has ruled in this case. See details on the decision at Nurse.com. Read details below on both sides of the argument and the impact a different decision would have had on patients.
The Affordable Care Act has had its share of critics and advocates since its enactment in 2010 and core measures went into effect in 2014. The future seemed unclear on how the ACA would fare in accomplishing what it was intended to do: Make healthcare available to everyone regardless of health or financial status. One critique has morphed, literally, into a federal case — King v. Burwell — in which the two sides differ on how subsidies can be used to purchase insurance through exchanges. The U.S. Supreme Court is expected to make a decision by the end of June.
What’s happening now
By the end of this month, the U.S. Supreme Court is expected to decide whether lower- and middle-income people in states without health insurance exchanges can continue to receive government funds to help them buy insurance. Four Virginia residents claim the subsidies are legal only in states that have established their own exchanges, but not in Virginia and other states that use a federal insurance marketplace. They base their argument on a line in the Affordable Care Act that says subsidies are for those buying insurance through an exchange “established by the state.” The Obama administration contends the line is being misread, and that the healthcare reform law clearly intends for subsidies to be used for insurance purchased through either a state or federal exchange.
The court heard arguments in early March on the case, which is called King v. Burwell, based on the name of one of the plaintiffs, David M. King, and Secretary of Health and Human Services Sylvia Matthews Burwell. Most legal experts predict the court will uphold the subsidies, but if it rules against them, about 6 million people in 34 states could lose their health insurance subsidies, according to the Department of Health and Human Services. People in affected states will be able to keep their insurance if they pay for it themselves, but if the cost of insurance exceeds 8% of their income, they will not face penalties for dropping it.
An Urban Institute report estimates about two-thirds of those who lose subsidies would drop their insurance. Those in states that have their own exchanges should not be affected, at least in the short term.
How it affects nurses in their practice
Many nursing organizations, including the American Nurses Association, support the ACA because it expanded insurance coverage to millions of people who didn’t have it, with the intention of increasing access to healthcare. If the court declares the subsidies illegal, those who receive them could see their premiums triple on average, according to a report by the Kaiser Family Foundation.
Nurses will likely have many questions from patients who receive subsidies and want to know if they will lose their health insurance, said Rose O. Sherman, EdD, RN, NEA-BC, FAAN, director of the Nursing Leadership Institute at Christine E. Lynn College of Nursing in Boca Raton, Fla. “In the states that don’t have exchanges, we’re going to be impacted.”
In Florida an estimated 1.3 million people could lose their subsidies, according to the Kaiser Family Foundation. “If they can’t afford the policy, what will they do?” Sherman said. Nurses could be working with patients receiving expensive treatments, such as chemotherapy, who will not be able to afford the insurance to cover it, she said. They may have patients who can no longer afford medications. People may put off care or be unable to pay for the care they receive, something that could affect hospitals in the state, she said.
Some Florida hospitals that were struggling financially have been able to turn things around in recent years, she said, partly because of an improved economy, but also because more insured patients were able to pay for healthcare, according to a report from Kaiser Health News. But an Urban Institute report released in February predicted healthcare spending could drop considerably if subsidies were eliminated and costs of uncompensated care could rise. “This would adversely affect both the amount of healthcare received by those losing coverage and healthcare providers’ revenues,” the report stated, particularly in states such as Florida that have not expanded Medicaid.
Another fallout for nurses could be a run on healthcare services. If people think they will lose their insurance in coming months, they may rush to schedule elective surgery and tests, similar to what happens at the end of the year with people who have met deductibles, Bob Seehausen, a senior vice president with healthcare system Novant Health, told the Charlotte Observer. “That would be a logical behavior.”
What to watch for in the future: Court decisions take effect about a month after they are issued, which means subsidies in affected states could stop in August if they are declared illegal. Some Republican lawmakers say they may be willing to temporarily extend the subsidies in exchange for dropping other parts of the ACA, such as the requirement that everyone have health insurance. Some have proposed replacing the ACA with a system of tax breaks to help people buy insurance on an open market, and high-risk pools for those with pre-existing conditions.
President Obama has threatened to veto any law dismantling or significantly changing the ACA, though he has offered flexibility in working with states who want to establish their own exchanges quickly. Some states, including Pennsylvania and New Jersey, have indicated they will immediately start working to create exchanges if subsidies for federal exchanges are declared illegal. Other states have not said what they will do. Federal officials say there is no national contingency plan if the court overturns the subsidies.
If the court upholds the subsidies, the ACA still faces some legal challenges in the future. One House Republican lawsuit charges federal funds used for subsidies were not properly approved. Another claims the administration illegally delayed provisions requiring employers to provide insurance for employees. Other pending cases involve the law’s requirement to cover birth control.
See details at the following links:
Cathryn Domrose is a staff writer.
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