State hospital association leaders predict dramatic health care changes if the ACA subsidies are overturned by the Supreme Court, which heard arguments in King v. Burwell yesterday.

The court’s ruling, which is expected to come in June, may decide the fate of federal subsidies for 7.5 million people in the 34 states that aren’t running their own insurance exchanges.

“Everyone I've talked to, on no matter what side of the political spectrum, is worried,” said Sean Connaughton, president and CEO of Virginia Hospital & Healthcare Association. “Even people who opposed the ACA have got to see the practical impacts if the administration loses.” The association expects 300,000 Virginians to lose coverage in such a case.

In Pennsylvania, four out of five people who are insured through the exchanges are receiving subsidies. That’s up to 400,000 Pennsylvanians who could lose their coverage, said Andy Carter, president and CEO of the Hospital & Healthsystem Association of Pennsylvania. “We’d be left with the most chronically ill, desperate folks who will hold on to their insurance with a death grip,” Carter said. “Premiums will go up or insurers will leave the market; then we’re left with Medicaid expansion.”

Hugh Tilson, executive vice president and COO of the North Carolina Hospital Association, echoes this fear. The state counts 515,000 people who have benefited from the subsidies — aid which, if lost, could eventually heighten the premiums of the otherwise insured.

“North Carolina did about $1.8 billion in uncompensated care and unreimbursed care for government programs last year alone,” said Tilson. “If those 515,000 North Carolinians lose coverage, they’ll turn to hospitals as safety nets to get care. Part of the problem we’ll have is: Those additional unreimbursed costs will come on top of the massive cuts we’re already experiencing from Medicare and Medicaid, which are approaching a billion dollars a year. The timing of it is really scary.”

Carter says he is optimistic that the court will avoid what would be a “profoundly disruptive and chaotic” ruling, but is taking steps to explore the possibility of a strategy for Pennsylvania to qualify for a state exchange, in case. He also is talking with state representatives to convey the importance of keeping the subsidies in place.

“We want people to be paying attention in June when the Supreme Court ruling comes down, so they aren’t just beginning to think about it,” he said.