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���������� Note: Having pored over numerous accounts of the nature and impact of yesterday’s decision by the Supreme Court to uphold an essential element of the Affordable Care Act (ACA), here’s my best attempt to present it in plain language.

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1. There a 3 main components of the Affordable Care Act

• Health insurance companies must sell insurance to everyone, even people who are currently sick or have a history of chronic illnesses, at a reasonable price and they cannot charge higher premiums depending on health (the “non-discrimination rule”).

• The law requires everyone to obtain health insurance or pay a penalty, in order to ensure that there’re enough payments from healthy people in the insurance pool to balance out the costly needs of people with greater or ongoing healthcare needs.

• The ACA offers subsidies to reduce monthly insurance payments and out-of-pocket costs in an effort to expand access to affordable health insurance for moderate and low-income people – particularly those without access to affordable coverage through their employer, Medicaid, or Medicare.��

  • There are two types of subsidies

  • a tax credit that works to reduce enrollees’ monthly payments for insurance coverage.

  • financial assistance, the cost-sharing subsidy, is designed to minimize enrollees’ out-of-pocket costs when they go to the doctor or have a hospital stay.

2. The ACA requires the development of healthcare exchanges, which are government-regulated marketplaces of insurance plans with different levels of coverage, offered to individuals without health care or to small companies.

��3. The federal government is implementing the program in the 34 states that did not set up their own healthcare exchanges. ���������� State and 15 other states operate their own exchanges.

��4. 4 Virginians sued the Obama Administration claiming that language in the ACA appeared to forbid the federal government from offering health care subsidies to individuals in the states that did not set up their own exchanges. Subsidies were not at risk in the 16 states that run their own exchanges.

5. By a vote of six to three, the Court agreed with the Obama administration that the subsidies are available for everyone who bought health insurance through an exchange, no matter whether that exchange was created by a state or the federal government.

��6. The Court concluded that the language in question was an ‘inartful’ drafting error, deciding that if the subsidies weren’t available in the states with federal exchanges, the program wouldn’t work properly, since without the subsidies, almost all of the people who purchased insurance on the exchanges would no longer be required to purchase insurance because it would be too expensive.�� It is “implausible,” the Court concluded, “that Congress meant the Act to operate in this manner.”

7. Several results from the decision:

• According to the Kaiser Family Foundation, this could have resulted in a loss of subsidies for more than 7.5 million people, the majority of which would not be able to afford health insurance without the subsidies.

• The National Council issued a statement that said that “this decision prevents 6.4 million Americans from losing affordable coverage that includes the parity protections set forth in the Affordable Care Act (ACA). These parity requirements ensure consumers can access affordable, quality care for both physical and mental health problems. Prior to the ACA, consumers with pre-existing conditions could be denied insurance, or offered coverage that excluded the key services they needed to manage their health. This was especially problematic for the millions of Americans living with addiction or mental health conditions, because so many plans either didn’t cover those services or imposed such burdensome restrictions that it was nearly impossible for people to access care.

• According to Open Minds’ Monica Oss, the decision means that “insurance marketplaces are here to stay…we’ll likely see more federal exchanges.” Monica also concluded that “value-based purchasing is on the fast track – The era of value-based payment, with its accountable care organizations (ACO), medical homes, and health homes, is likely to continue at the current breakneck pace. With preexisting condition exclusions, no lifetime care limits, medical loss ratio requirements, and more, health plans will continue their search for value in the new financial paradigm.” See more at

• According to NYC Health and Hospitals Director Dr. Ram Raju as reported in today’s Crain’s Health Pulse, “the decision averted disaster for public hospital systems in the 34 states where subsidies were at risk. They would have had an uptick in uninsured patients.”

�� 8. Many Republican lawmakers are saying it’s time to move on from Obamacare repeal, according to Politico. “Republicans have tried to kill the health care law twice at the Supreme Court, only to be rebuffed. They’ve held more than 50 repeal votes, virtually all of which have died in the Senate. They tried to defund the law through the spending process, but the government shut down instead.” GOP reactions ranged from defiance to resignation.

Many, like Rep. Robert Aderholt (R-Ala.), concede the law is here to stay until at least 2017, when they hope a GOP president will finally kill it. But conservatives like Texas Sen. Ted Cruz insist Congress should use “every single tool at our disposal” now to stop the law, including holding spending bills hostage to force President Barack Obama to acquiesce.

Still others, such as Rep. Ed Whitfield (R-Ky.), say it’s time to focus on fixing aspects of the existing law, rather than continuing a fruitless repeal effort. Rep. Tom Cole (R-Okla.), an ally of Speaker John Boehner’s, said the party should focus on reforms “you might be able to talk the president into,” such as changing how Medicare benefits and Social Security cost-of-living adjustments are doled out. ��

“It means that the most significant domestic issue in 2016, at every House race, in every Senate race and for president will be centered around whether or not the country wants to keep Obamacare,” said Sen. Lindsey Graham (R-S.C.), who is seeking his party’s nomination for the White House. And if Hillary Clinton wins, Graham said: “It means that Obamacare becomes Hillarycare.”

“At the end of the day, there is not going to be any complete repeal of the law until there is a new ��Administration,” Aderholt said. Republicans will have a Avery hard time changing the law even if they sweep the 2016 elections. The Senate will likely be narrowly divided, and the vast majority of the Affordable Care Act will already be in place and relied upon by tens of millions of people.

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