Immediately after the Supreme Court’s 6–3 ruling last month declaring that federal subsidies were legal for people who buy coverage on the federal health insurance exchange, proponents and opponents staked out their usual positions on the political spectrum. Looking beyond the congressional and presidential election battlegrounds though, some policy experts will be paying close attention to how private insurers and state lawmakers respond.

Paul Keckley, managing director, Navigant Center for Healthcare Research and Policy Analysis, says insurers will face a tough next few months. The individual insurance market is risky and challenging, and rate filings are pricing plans with sizable hikes.

“It’ll be interesting to see how the insurance companies now communicate about this to, not just the 6.4 million who would have been affected [if the ruling had gone the other way], but doctors and hospitals about what it means and what to look for,” Keckley says. “There’s still a lot of anxiety out there in the market and the rate filings suggest that health insurers are going to be all over the place in their requested increases. I think that’s one to watch.”

On the Medicaid front, John Ayanian, M.D., director of the Institute for Healthcare Policy and Innovation at the University of Michigan, will be watching to see if more states seek to expand coverage, provided they’re granted flexibity from the federal government.

Michigan’s expansion included greater cost sharing, financial incentives for healthy behaviors and health savings accounts. Similar leniency has been granted to Arkansas, Indiana and Pennsylvania.

“The ruling provides more stability for the law overall, and the investments made by insurers and providers in extending coverage and access to care to those newly enrolled can now be sustained,” Ayanian says. “We may see opportunities for more flexibility in the design of Medicaid across states that could entice more to participate in the expansion.” 




“Congress passed the Affordable Care Act to improve health insurance markets, not destroy them.”

Chief Justice John Roberts
Writing the opinion for 6–3 majority in King v. Burwell

“Words no longer have meaning if an exchange that is not established by a state is ‘established by the state.’ ”

Associate Justice Antonin Scalia
Writing the dissenting opinion in King v. Burwell

“We are celebrating today. It is a victory for working people. It supports access to coverage and the steps we are taking to transform the delivery system.”

Sally Jeffcoat
Executive vice president West/Midwest Group Trinity Health

“In the short time the subsidies have been available, hard-working people who are sick, need care for chronic conditions, or want preventive care have been able to seek care more easily.”

Rich Umbdenstock
President and CEO American Hospital Association

“And we will continue our efforts to repeal the law and replace it with patient-centered solutions that meet the needs of seniors, small business owners and middle-class families.”

Rep. John Boehner Speaker of the House