Ohio mom worries that court ruling could threaten her family's health insurance

Kristen Clark remembers the days when buying health insurance used to be not only complex but also prohibitively expensive. “A lot of times, it's like paying a second mortgage,” she said.

The looming U.S. Supreme Court ruling threatening to wipe out premium subsidies in up to 37 states could force Clark and millions of other Americans to experience those days all over again.

Clark, 31, her husband, and their two daughters live in Delaware, Ohio, just north of Columbus. She is a stay-at-home mom, and her husband is a minister earning a modest income. This year, they bought coverage on Ohio's federal exchange from InHealth Mutual, the state's not-for-profit co-op insurer created under the Affordable Care Act.

Her family is relatively healthy, Clark said. Like most people, she wants health coverage for her children and to protect against worst-case scenarios. The plan they bought had all of their doctors in network. They received a subsidy under the ACA, which cut their monthly premium by about half, to less than $400 per month. “It helps having a subsidy because we can afford it a whole lot easier,” Clark said.

The Supreme Court is scheduled to issue its decision in King v. Burwell this month, and those premium subsidies are in danger. The plaintiffs argue that premium tax credits are only available through “an exchange established by the state” and not through the federally run exchanges. The Obama administration argues that the law read in its entirety makes clear that subsidies are allowed in all states.

Ohio is one of 37 states using the federal marketplace. It's questionable whether its Republican-controlled government would be willing to establish a state-run exchange if the Supreme Court kills the subsidies.

A loss of subsidies in these states could throw the entire individual health insurance market into chaos. Premiums for exchange plans would jump 287% on average across the country, according to the Kaiser Family Foundation. An estimated 6.4 million people who live in states using the federal marketplace would lose subsidies, and most would be expected to drop coverage because it would no longer be affordable.

Clark said she and her family would do whatever they could to keep their insurance. But adding hundreds of dollars to their monthly bill would be a big burden. “When you're already living on one income, that would not make it easy to do,” she said.

Jesse Thomas, CEO of InHealth Mutual, the plan chosen by Clark and her husband, said about half of his plan's 22,000 members bought plans through the federal exchange. More than 80% of Ohio's exchange enrollees receive premium tax credits. Overall, Ohio has about 189,000 exchange enrollees, 85% of whom receive subsidized coverage.

Thomas believes his plan has injected a new source of insurance access and competition for Ohioans looking for health coverage. Now the King case has created major uncertainty for people who want to keep their health plans. “If you have 80-plus percent that rely on those subsidies, it's going to have an impact,” he said.

Many hospital and medical leaders have warned that tossing the subsidies would plunge the system into chaos. Dr. Jay Shannon, CEO of Cook County Health and Hospitals System, said charity care at his safety net system in Chicago has dropped the past two years under the ACA's coverage expansion. Without premium subsidies, charity care would likely bounce back to previous levels. Many people would fall into the category of being too poor to afford health insurance but not poor enough to be eligible for Medicaid.

“I can't imagine, both at the personal level and at the state level, how the Supreme Court could imagine that working out for the good,” Shannon said. “That's unbelievably cruel.”

Legal experts are split on how the high court will rule. Renee Landers, a law professor at Suffolk University and former deputy general counsel at HHS, predicts a 6-3 victory for the government, but with no majority opinion. Chief Justice John Roberts and Justice Anthony Kennedy may uphold the subsidies for different legal reasons than the four liberal justices, she said. That could create additional political uncertainty about the future of the subsidies.

In the just-as-likely scenario of the subsidies being invalidated, Landers sees a destructive effect on lower- and middle-income Americans. “I don't think the (ACA) is perfect, but I think it has given a lot of people the opportunity to have some health insurance, which gives them some peace of mind,” she said.

Clark was not aware of the King v. Burwell case until she was interviewed Thursday by Modern Healthcare. She and her family are in the process of moving, and it hasn't been a priority for her to keep up with Supreme Court news. Now knowing what's at stake, she expressed concern. “It would definitely affect us,” she said. “It would add a whole lot more stress.”