In a few weeks, the U.S. Supreme Court takes up another challenge to President Barack Obama’s health care law. This time, it’s a claim that only people who buy their insurance through state-based exchanges qualify for the federal subsidies in the law.
The case is a pretty close call, but if the justices agree with the law’s challengers, more than 6 million Americans who bought their coverage through HealthCare.gov would soon have to pay for it entirely on their own.
Republicans believe that would lead to the collapse of Obamacare.
It wouldn’t. The case turns on the words in the law, not its constitutionality. Obamacare would survive whatever the court decides.
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But the ruling would have practical and political consequences. If health insurance subsidies were limited to states with their own exchanges, Missourians and Kansans who used the federal exchange probably would drop their coverage — jeopardizing their health care while adding to the burden on hospitals that are struggling with federal subsidy cuts of their own.
Some Republicans, fearing disruption, want the White House to plan ahead. They want a temporary extension of the subsidies until buyers in states without exchanges can adjust.
There is an easier fix, though. States without exchanges could just start them, qualifying their residents for the federal help.
Such a step seems doubtful in Kansas and Missouri. Lawmakers in both states repeatedly have refused to establish health insurance exchanges.
Of course, maintaining that position would mean Obamacare taxes would subsidize health coverage for New Yorkers and Californians while Missourians and Kansans would go without.
State legislators seem OK with that. After all, they already have declined to expand Medicaid despite a similar subsidy issue.
Those positions may not be defensible, but they increasingly put state-based Republicans at odds with a chorus of national party figures who are worried about the poor economic prospects of the middle class.
Likely GOP presidential candidates, from Jeb Bush to Scott Walker, now are burnishing their middle-class credentials. A Republican health care alternative contains tax credits for insurance, just like Obamacare.
At the same time, though, to pay for tax cuts, state lawmakers in the party have chipped away at middle class public services such as education, transportation and hospital care.
The Republican Party will have to decide soon which approach it prefers. The coming Supreme Court decision will accelerate that discussion.