The Supreme Court’s decision in King v. Burwell, the challenge to Obamacare pushed by right-wing activists, could come as soon as tomorrow. If the plaintiffs win, subsidies to help low-to-moderate income people in more than 30 states, including Arkansas, would suddenly halt. Insurance markets would be thrown into chaos and millions of Americans would lose their health insurance. In Arkansas, somewhere in the neighborhood of 48,000 to 58,000 people would lose subsidies — most would no longer be able to afford coverage; those desperate to hang on to coverage would face an average hit of $1,700 for the remainder of 2015 alone. 

Things get even worse in 2016: the loss of subsidies would lead to adverse selection — healthier people who could no longer afford insurance would leave the marketplaces, which would lead to rising premiums. That leads to even more healthy people leaving, and even higher premiums. This is what is known as a “death spiral” in insurance markets. Those losing subsidies would be hit hardest — Arkansans losing subsidies might be hit with de facto premium increases of 450 percent. But keep in mind that rising premiums would also hurt everyone else shopping on the marketplace. That means anyone buying individual insurance, regardless of income, who doesn’t get health coverage from a job or a big public program like Medicare. A win for the plaintiffs would hurt them too, via rising premiums. The number of Arkansans getting screwed by this situation will be growing rapidly in the coming years as people transition off of plans non-compliant with the health care law and onto the Marketplace. 

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Here’s the picture if the plaintiffs win: millions of Americans would lose billions in subsidies (and billions more in cost-sharing reductions, which means their deductibles and out-of-pocket maximums would suddenly be much higher than what they thought they were purchasing earlier this year). The ranks of the uninsured would grow by an estimated 8 to 9 million in 2016. And the health insurance markets in 34 states would face catastrophe and skyrocketing premiums for anyone hoping to purchase non-group health insurance. 

That’s not a pretty picture! Congress could immediately resolve the issue, restoring subsidies with a one-sentence fix (the lawsuit hinges on four-word technicality in the statute). With millions of low-to-middle income Americans either losing their insurance plans or facing massive de facto tax increases, there will be tremendous pressure to do something. After all, these are folks who purchased health insurance in good faith, at a certain price with certain coverage levels, only to have that snatched away by the Court (in full disclosure, my wife and I would be among those losing subsidies). That won’t sit well with many voters’ intuitive notions of fairness. Unfortunately the chances of  the GOP-controlled Congress passing a simple fix, even for the remainder of 2015, are next to zero. That would be seen as surrender to Obamacare.

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Instead, the plan among congressional Republicans appears to be veto bait. They’ll refuse to help the millions of Americans losing subsidies unless they can first extract demands that President Obama will never give, including repealing the law altogether. Then they’ll try blaming the president. Here are some features of the plan that House leadership is peddling, according to the National Journal:  

* Continue the Affordable Care Act’s subsidies through the end of 2015, absent a Court stay of its decision that did the same.

* Immediately repeal the individual and employer mandates.

* Starting in 2016, states would be allowed to opt out of the law and its other various regulations. States would receive a block grant, the same amount as the subsidies that their residents would receive, to implement their own health care plans.

* In states that don’t opt out, individuals would continue to receive subsidies but could use them to purchase plans on and off of the ACA exchanges.

* The plan would sunset in 2017, compelling a new Congress and president to come up with a comprehensive Obamacare replacement.

The first thing to note is that this plan, like all GOP half-hearted hints at plans, is centered on repealing the Affordable Care Act altogether. The GOP House leadership was explicit about this with reporters: under this proposal, Obamacare would end in 2017. Citizens dependent upon the law for affordable health insurance would then have to hope and pray that Republicans finally made good on their years-old promise to coalesce around a concrete plan to “replace” Obamacare. Good luck! 

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Meanwhile, Obama is not going to agree to repeal the individual mandate, the law’s requirement that everyone have health insurance. That will never poll well but it’s a key component of the law necessary to avoid the adverse selection mentioned above. Nix the individual mandate and some healthy people would opt out, sending costs up for everyone getting coverage on the marketplaces. The Obama administration has been clear that this is a non-starter. 

Then there’s some hand-waving about block grants on a timetable that would be impossible for states to implement. Consumers would face chaos in 2016 — not just rising premiums, but likely state-by-state confusion about what benefits and subsidies were even available, with open enrollment set to begin in about three months. But never mind, Republicans don’t seriously think this is going anywhere. They’re just taking a shot at the blame game, knowing that Obama is sure to veto. 

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All of this assumes that a rump group of Tea Party Republicans won’t join Democrats in blocking the poison pill bill (continuing subsidies for even a moment counts as surrender for some diehards). Either way, this is a sham: a DOA bill that is as good as nothing for the millions of Americans who will face immediate harm if the plaintiffs prevail in King v. Burwell. 

The strangest part of this is that the Republican plan does acknowledge that millions of people (the majority of them in Republican states and congressional districts) will be seriously harmed if they lose their Obamacare subsidies. That’s the potential emergency that House Republicans are trying to deal with: Americans losing a key portion of Obamacare! (Shouldn’t House Republicans be rejoicing if one of the main coverage mechanisms of the hated Obamacare law is nixed?) The simplest way to protect people losing subsidies is to…restore subsidies. Instead you have this charade: Republicans say that Obamacare is terrible, but it’s very important to make sure people don’t lose Obamacare subsidies, so…let’s repeal Obamacare. 

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Here’s how Greg Sargent at the Washington Post sums it up:

Republicans are offering this plan to draw a veto, in hopes of blaming Obama for the failure to extend subsidies. They will pair that argument with the claim that the law itself is at fault for all those millions of people losing them. The GOP argument is basically this: Obamacare is to blame for the awful outcome of millions of people losing Obamacare, so Republicans will protect all those people from Obamacare by temporarily restoring their Obamacare, before repealing it entirely for all its beneficiaries, and replacing it with … “oh, wow, look over there, a unicorn is wandering through the Capitol!”

At least the Tea Partiers who believe that the best response to King is simply to do nothing at all to restore subsidies are being honest. 

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The dynamic here is bleak for anyone dependent upon the law’s subsidies in the 34 states in jeopardy. Congress could easily solve the crisis but they won’t — the GOP leadership will simply try to shift the blame. That will almost certainly leave things up to the states, in a repeat of the Medicaid expansion fight. Blue states will presumably quickly shift to state-run marketplaces to protect subsidies for their residents. In Arkansas? We shall see. With the Court set to make a ruling this month, tens of thousands of Arkansans have reason to be very nervous.

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