The U.S. Supreme Court is hearing arguments in a major test of President Barack Obama's health overhaul that threatens insurance coverage for millions of people.
The case being argued Wednesday is just the latest challenge to the law that was Obama's attempt to bring universal health care to the United States.
In King v. Burwell, the Court will decide whether the Affordable Care Act permits government subsidies for citizens of at least 34 states which use the federal HealthCare.gov marketplace to buy health insurance. It will hear oral arguments on Wednesday.
If the justices rule that only residents of states running their own exchanges are eligible for subsidies, some 9.3 million people will have to pay their full monthly premium or lose coverage, estimates the nonpartisan Urban Institute. Anywhere from six to eight million are expected to be unable to afford it.
Three years ago, opponents of the act failed to kill the law in an epic, election-year Supreme Court case in 2012. Chief Justice John Roberts joined with the court's liberal justices and provided the crucial vote to uphold the law in the midst of Obama's re-election campaign.
The chief justice could again hold the pivotal vote in the current case.
"This case is no less important to the future of the Affordable Care Act" than the court's decision in 2012, said Erwin Chemerinsky, dean of the University of California at Irvine law school.
Parties to get out their message
A ruling that limits where subsidies are available would have dramatic consequences because roughly three dozen states, many run by Republican governors, opted against creating their own marketplace, or exchange. Instead, residents of these states rely on the U.S. Health and Human Services Department's healthcare.gov. exchange to get coverage if they don't get insurance through their jobs or the government.
House Rules Committee Chairman Pete Sessions, R-Texas, has been among the ardent Republican critics of the Patient Protection and Affordable Care Act, often called Obamacare. (J. Scott Applewhite/The Associated Press)
While Democrats dread losing the case, there's a risk for Republicans too: millions of voters in Republican-governed states would lose their subsidies. Many of those states have Republican senators up for re-election in 2016.
Republicans claim the law infringes on individual liberties by requiring almost everyone to have insurance and results in Americans paying more and getting shoddy care.
The new case, part of a long-running political and legal fight to get rid of the law also known as "Obamacare," focuses on four words — "established by the state" — in a law that runs more than 900 pages. The challengers say those words are clear and conclusive evidence that Congress wanted to limit subsidies only to people in states that set up their own exchanges. Those words cannot refer to exchanges established by the federal government, the opponents argued.
The Obama administration, congressional Democrats and 22 states argue that it's absurd to suggest they would have constructed the law the way its opponents suggest — which would undermine their own program. They say the full law makes clear there is no such distinction between federal and state exchanges. But with Republicans controlling Congress, Democrats have little hope of tweaking the law's language.
The idea behind the law's structure was to decrease the number of uninsured. The law prevents insurers from denying coverage because of "pre-existing" health conditions. It requires almost everyone to be insured, so that healthy people can offset the costs of the sick, and provides financial help to consumers who otherwise would spend too much of their paycheck on their premiums.
Both sides in the case argue that the law unambiguously supports only its position. So far, lower courts have been split on the issue. The court is expected to rule by late June.
Democrats and Republicans plan to use an array of tools - from social media and radio interviews to newspaper opinion pieces, news conferences and Senate and House of Representatives floor speeches - to bolster the opposing legal arguments being laid out before the high court and to rally public opinion.
On Twitter, for example, at #acaworks, Senate Democrats brim with upbeat assessments of how Obamacare has slashed the numbers of uninsured while also saving on seniors' drug costs.
One tweet features an Obama quote: "While affordable health care might still be a threat to freedom on Fox News ... it's working pretty well in the real world."
Senator John Barrasso of Wyoming, a member of the Republican leadership, is spearheading his party's efforts in the Senate to land a deadly blow to Obamacare, which is opposed by 53.5 per cent of Americans, according to a recent Reuters/Ipsos poll.
Physicians thinking about Plan B
Interviews conducted by Reuters with doctors reached through professional groups show that they are preparing for a successful court challenge just in case, lining up free clinics to care for patients with chronic illnesses, asking pharmaceutical companies to provide discounted drugs, and moving up preventive-care appointments and complicated procedures.
"We have to be able to navigate this on behalf of our patients if it comes about," said Dr. Jeff Huebner, a family physician in Madison, Wisconsin, one of the affected states.
Parkland Hospital financial councilor Ricky Spain, right, answers questions for Gregory Jackson and his wife Tameka Jackson as they waited in to sign up for health care insurance in March 2014. (LM Otero/The Associated Press)
Last weekend, leaders of the National Physicians Alliance, which supports the Affordable Care Act and works to improve access to medical care, met in Washington to discuss how to work with community organizations to arrange health care for people who might become uninsured, said Huebner, who chairs the group's policy committee.
"The ideas include finding organizations that make referrals to free clinics, encouraging patients to check if they qualify for Medicaid or other state programs, and if they can't get insurance then find a regular source of care that accepts payment on a sliding scale" based on ability to pay, Huebner said.
"I would advise patients in this boat to schedule a visit with their primary care provider as soon as they can" to set up "transition plans," he added.
Dr. Robert Wergin, a primary care physician in Milford, Nebraska, is scrambling to locate labs and imaging centres that offer the lowest prices for blood tests, X-rays and MRIs.
"Around here, people feel responsible for their bills and I'm not sure they would come in if they lost insurance and couldn't pay," Wergin said.
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