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After court ruling, Affordable Care Act faces more certain path

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After surviving yet another legal challenge this week, the Affordable Care Act appears poised to remain a critical part of the fabric of the nation’s health care system.

The Supreme Court’s ruling Thursday to uphold government subsidies to defray the cost of health insurance gave President Barack Obama a big victory. Had the court ruled another way, state and federal lawmakers would have had to go back to the drawing board for health policy.

Instead, the ruling means the law can continue, uninterrupted, to transform how health care is delivered in America and the focus can shift to fully carrying out its other components.

Since its passage, the Affordable Care Act has upended the entire health care sector.

More than 16 million people have become insured under the law, and many more still could. Hospitals and other medical providers are increasingly being paid based on the quality of care, as opposed to the quantity of services rendered. Patients are being asked to share more of the burden through higher deductibles and copays, and insurance prices remain volatile.

The court decision in favor of the Obama administration also brought renewed focus to another controversial part of the law, one of the last key pieces still up for political debate.

The president was quick to point out that many states have yet to add more low-income residents to their Medicaid programs, as called for by the law. With the court ruling behind them, administration officials can now turn more toward pressuring reluctant states.

“I’m going to work as hard as I can to convince more governors and state legislatures to take advantage of the law, put politics aside and expand Medicaid and cover their citizens,” Obama said in a statement at the White House about an hour after Thursday’s ruling.

Just as quickly came a reminder of continued opposition to Medicaid expansion in Missouri by Republicans who control the state Legislature.

“I will continue to fight Medicaid expansion at every step,” tweeted Sen. Kurt Schaefer, R-Columbia. Schaefer chairs the Senate Appropriations Committee, which would have to approve funding for Medicaid expansion, and is running to become state attorney general in 2016.

Obama’s law gives states the option to use mostly federal dollars to expand their Medicaid health insurance program. But Missouri and 20 other states have resisted, citing concerns about the long-term costs. State officials estimate that Medicaid expansion in Missouri could cover about 300,000 more people.

While opposition to Medicaid expansion shows few signs of subsiding, other aspects of the law can now hit their stride after the court’s decision.

Open enrollment for private insurance is scheduled to begin again in November and administration officials are reviewing early plan prices and designs. Early estimates show premiums are rising in some markets, but at a relatively modest pace. Health officials pledged to continue to work on reducing costs.

The administration can also turn its focus toward the Affordable Care Act’s payment incentives, which are designed to bring down prices and promote quality care. It has set a goal of tying 90 percent of Medicare payments to quality measures by 2018. The court decision gives officials more time and energy to focus on that goal.

“We have the opportunity to transform the health care system in unprecedented ways,” said Health and Human Services Secretary Sylvia Burwell after the court’s ruling. “We can now turn to doing the things we need to do.”

Despite this week’s victory, challenges remain for the Affordable Care Act.

Republicans, who have opposed the law from the beginning, criticized the court and said they remained committed to their goal of repealing it.

“Obamacare is fundamentally broken,” House Speaker John Boehner said in a statement Thursday. “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.”

But they also acknowledged that goal would need to wait until after the 2016 elections, which could bring in a Republican president. Even then, experts say, efforts to repeal or substantially roll back the law may not succeed.

“The more people that use these marketplaces and get insurance and receive financial help, I think, the harder it is to take away benefits from those people,” said Ryan Barker, vice president of health policy at the Missouri Foundation for Health.

Some parts of the law that have yet to be carried out may also prove contentious and controversial. In 2018, the law’s so-called “Cadillac tax” on expensive employer-sponsored plans is slated to take effect. Such a large tax on employers is bound to provoke controversy but ditching it wouldn’t have nearly the damaging effect on the law overhaul as a decision against the subsidies would have.

States that operate their own exchanges are also facing financial woes, which could put more pressure on, the federal exchange.

But after the court’s ruling it appears for now that, in the words of Obama, the Affordable Care Act is here to stay.

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Jordan Shapiro is a reporter for the St. Louis Post-Dispatch.

Related to this story

It’s unusual when Democratic presidential candidates Hillary Clinton and Bernie Sanders are on the same page as they compete for primary voters. It’s even more unusual when labor unions and the U.S. Chamber of Commerce are singing the same song.

But Obamacare’s so-called “Cadillac tax” is bringing these and many more disparate political bedfellows into unison. (And some people still complain that President Obama’s policies are divisive.)

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