DAVID GREENE, HOST:
The future of Obamacare may very well hinge on six words in the law. Exactly what they mean is at the center of a new challenge in the Supreme Court. Opponents of the law argue that the text does not authorize subsidies to make mandated insurance affordable in 34 states. It is a technical argument, but if it prevails, most experts say the Affordable Care Act could unravel chaotically. In 2012, a bitterly divided High Court upheld the law as constitutional by a 5-to-4 vote. In the legal boxing ring of the Supreme Court, it is time for round two. Here's NPR legal affairs correspondent Nina Totenberg.
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NINA TOTENBERG, BYLINE: In one corner, the Obama administration, backed by the nation's hospitals, insurance companies, physicians associations and groups like Catholic Charities and the American Cancer Society.
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TOTENBERG: In the other corner, conservative groups, backed by politicians who fought in Congress to prevent the bill from being adopted. What they're all fighting about is six pesky words in a subsection of the law. Those words stipulate that for people who cannot afford health coverage, subsidies are available through, quote, "an exchange established by the state."
The government contends that those words refer to any exchange, whether it's set up by the state itself or an exchange run for the state by the federal government in accordance with each state's insurance laws and regulations. The challengers say the statute means what it says and no more.
If the Supreme Court agrees with the challengers' interpretation, millions of people would quickly lose their health insurance and the individual insurance market could collapse in 34 states. Those are the states - mainly Republican-run - that declined to set up an exchange themselves. A few other states also found the system they created on their own didn't work well and so opted instead for federal help. Every major regulatory law like the Affordable Care Act is carried out according to regulations issued by the appropriate agency. In this case, the IRS issued a regulation saying that subsidies would be available to people who signed up on exchanges in every state, whether state-run or federally-run. That was the whole design of the law, the IRS said, noting that Congress never even discussed limiting subsidies to state-run exchanges. Enter the challengers and their lawyer, Michael Carvin.
MICHAEL CARVIN: The law is very clear. It says you get subsidies if you make a purchase on an exchange established by the state. And the IRS says you get a subsidy even if it's an exchange established by HHS, which is in 34 states. So the rule that the IRS came up with is opposite to the law that was passed by Congress.
NEAL KATYAL: You can take a phrase out of any statute and twist it to mean something else.
TOTENBERG: Former Obama administration Solicitor General Neal Katyal has filed a brief in the case on behalf of the nation's major hospital groups. Katyal points out that a basic maxim of interpreting statutes is to look at the overall purpose and structure of the act.
KATYAL: It's notable that in all the thousands of pages of briefing that the Affordable Care Act challengers have put together, they can't find a single member of Congress at any point in the many debates of the Affordable Care Act who believes what these lawyers are saying - not one.
TOTENBERG: Indeed, even Republicans did seem to assume that the subsidies went to everyone who needed them, regardless of where they lived. Here, for instance, is Paul Ryan in 2010, the top Republican on the House Budget Committee.
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REPRESENTATIVE PAUL RYAN: It's a new open-ended entitlement that basically says to just about everybody in this country, if your health care expenses exceed anywhere from 2 to 9.8 percent of your adjusted gross income, don't worry about it. Government's going to subsidize the rest.
TOTENBERG: And here's Wisconsin Governor Scott Walker.
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GOVERNOR SCOTT WALKER: In the end, there's no real substantive difference between a federal exchange or a state exchange.
TOTENBERG: Although some of the challengers initially portrayed their case as involving a drafting error or glitch, Michael Carvin says the language restricting subsidies to state-run exchanges was deliberate.
CARVIN: The only people who ever said it was a drafting glitch were liberal polemicists who were trying to deny the force of the statute, not us.
TOTENBERG: He notes that those words limiting subsidies to an exchange established by the state actually appear in the statute 11 times, and he contends that the whole idea was to provide incentives for states to set up exchanges themselves.
CARVIN: They wanted subsidies, and they wanted state-run exchanges. If you condition the subsidies, you get both. If you give unconditional subsidies, you don't get state-run exchanges.
TOTENBERG: Not so, says former Health and Human Services Secretary Kathleen Sebelius, who says the conditional subsidy idea would lead to, quote, "absurd results."
KATHLEEN SEBELIUS: You would have in place a national rule that says no company could ban people with a pre-existing condition. You would have a national rule that said everybody has to have coverage. And then you would have millions of people who would have no affordable way to get that coverage.
TOTENBERG: What's more, she says, a conditional plan such as Carvin outlines would amount to bait and switch for the states.
SEBELIUS: As one who was not only at the table when the law was being designed and at the front end of a lot of conversations with states, I can tell you that there was never a design that in any way suggested to governors or state leaders that somehow, if they did not have a state-based marketplace, they would lose tax subsidies for their constituents.
TOTENBERG: But what would happen if the Supreme Court doesn't buy that argument and instead knocks a huge hole in the law? Estimates are that 9.3 million people who now get subsidies through Obamacare in those 34 states would lose about $29 billion in subsidies and would not be able to afford coverage. In addition, experts say that disallowing the subsidies in the federal exchange states would destabilize the individual insurance market in those states, meaning that rates would skyrocket by as much as 75 percent for individuals and many small businesses that currently buy policies independent of the federal exchange.
Karen Ignagni, who heads the association that represents the nation's health insurers, notes that without subsidies, those 34 states would be in the same position as states in the 1990s that passed laws banning discrimination based on previous medical conditions, but did nothing else.
KAREN IGNAGNI: If you look at each and every state where they tried to do that, the markets blew up.
TOTENBERG: Without a mandate and subsidies to make coverage affordable, rates skyrocketed, people dropped out and rates skyrocketed even more to cover the older, sicker people who were left. So thoroughly did the individual market collapse in some states that insurers simply refused to do business there. The prospect of such chaos in the health industry, which accounts for almost 18 percent of the U.S. economy, is perhaps the reason that business groups which aggressively backed round one of the legal attack on Obamacare are nowhere to be found in round two.
Certainly, Congress could fix the problem with a quick drafting change to make subsidies available on federal as well as state-run exchanges. But everyone knows that isn't going to happen. Congressional Republicans seem united on the idea of getting rid of Obamacare. Indeed, the GOP-controlled House has voted to repeal the law in whole or in part more than 50 times. But there's no agreement at all on what to replace it with. And in the states, some Republican governors and state legislatures are already vowing not to sign on to exchanges to save subsidies for their constituents. There is, of course, always political danger in such brinksmanship. Real people suffer the consequences. Nina Totenberg, NPR News, Washington.
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