The Supreme Court’s decision to uphold a key part of President Barack Obama’s health law did more than preserve subsidies for millions of Americans. For the second time in three years, it helped cement his legacy.

“After multiple challenges to this law before the Supreme Court, the Affordable Care Act is here to stay,” Obama said in the White House Rose Garden, standing before a phalanx of news media and aides. “Today is a victory for hardworking Americans all across this country, whose lives will continue to become more secure in a changing economy because of this law.”

In 2012, the health law survived a constitutional challenge and later that year became a major issue in the president’s re-election campaign. The Republican-controlled House has voted more than 50 times to repeal the law.

In his 10-minute talk, Obama reminded Americans that the law is working and stressed that it has helped slow rising health costs to their lowest rate in 50 years.

“The point is, this is not an abstract thing anymore,” he said.  “This is not a set of political talking points.  This is reality.  We can see how it is working.  This law is working exactly as it’s supposed to.  In many ways, this law is working better than we expected it to.”

The president said he would become more active in working to persuade Republican governors and state legislators to expand Medicaid under the law. The Supreme Court in 2012 made Medicaid expansion optional for states. Twenty-one states, including Florida and Texas, have yet to adopt it. “We still have states out there that for political reasons are not covering millions of people,” Obama said.

Republicans have shown no willingness to drop their opposition to the law, which has helped reduce the uninsured rate in many states by half since 2014.

Senate Majority Leader Mitch McConnell, R-Ky., said in a statement the law continues to be bad for America. “Today’s ruling won’t change Obamacare’s multitude of broken promises, including the one that resulted in millions of Americans losing the coverage they had and wanted to keep,” he said.

Sen. John Barrasso, R-Wyo., was even more blunt: “We are going to continue to work to repeal and replace this health care law,” he said on the House floor.

Obama said he knew the law is still misunderstood and even people who enjoy its benefits don’t realize their connection to it. He noted when people gain either subsidized coverage or Medicaid, they don’t get an “Obamacare card.”

“This has never been a government takeover of health care,” Obama said, responding to a common GOP sound bite.

Obama compared the impact on Americans to the passage of Social Security in the 1930s and of the creation of Medicare and Medicaid in the 1960s. He said the health law made sure all Americans have access to health care insurance regardless of where they live or their health condition. “This generation of Americans chose to finish the job….This was a good day for America.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Despite having survived a challenge in the U.S. Supreme Court, the federal government’s health insurance markets face weighty struggles as they try to keep prices under control, entice more consumers and encourage quality medical care.

The government’s insurance markets – as well as more than a dozen run by states — have been operating for less than two years and are about to lose their training wheels. Start-up funds that have helped stabilize prices and partially pay for administration of the marketplaces are ending, feeding fears that premiums may rise after next year at a steeper rate.

There are still 18 million uninsured people who are eligible for coverage but have not purchased insurance. Without broader participation, insurers may be pressed to raise rates as they get a more complete picture of how much medical care their current customers are using.

“It has proven to be harder to get people to sign up for exchanges and keep them than experts expected,” said Caroline Pearson, an executive at Avalere Health, a Washington consulting firm. “Hispanics, young people and men are still lagging in enrollment and it still seems like the exchanges have not figured out how to reach them.”

Insurers in a handful of states have proposed increasing premiums for the cheapest “silver” plans by an average of 4.5 percent next year, according to an analysis by Avalere. That was slightly higher than last year’s 4 percent increase for the cheapest silver plans in all states, Pearson said. Consumers who want to stick with their current plans may see larger increases, as insurers are trying to enact double-digit price increases for some policies.

Burden For Consumers 

More than 10 million people buy insurance through the online marketplaces set up by the Affordable Care Act, or ACA. About six of every seven of those people are getting financial assistance from the federal government. Even with that help, health care costs can be substantial, with premiums for some reaching nearly a tenth of their gross incomes.

For instance, families of three earning $73,000 have to pay nearly $7,000 on premiums despite also receiving subsidies They still face deductibles, which this year averaged around $2,500 for the most common types of insurance plans, known as silver tiers. If a family required extensive medical care and reached the maximum they would be held responsible for—$13,200 this year—their total health care-related bills, including premiums, would exceed $20,000, or 28 percent of their gross incomes.

“Even some of those who are eligible for financial assistance are still finding the coverage not to be affordable for them,” said Linda Blumberg, a senior fellow at the Urban Institute, Washington think tank.

With the end of start-up funds from the federal government, exchanges need to support their continuing responsibilities, which include running the call centers that offer consumer assistance, operating the exchange websites where people choose plans and marketing their efforts to encourage the uninsured to sign up. Most exchanges, including the federal healthcare.gov site, are funded through an assessment on each plan that is sold, although some receive support from state budgets. Revenue has been volatile, and some marketplaces have been caught short when lower enrollment or smaller premiums led to smaller fees.  Some states are considering handing their marketplaces over to healthcare.gov.

“We don’t have a clear sense of how much it costs to maintain these programs,” said Kevin Lucia, project director at Georgetown University’s Health Policy Institute.

If premiums rise, the bill for federal taxpayers who fund the subsidies will increase as well. The government has been giving insurers some breathing room by limiting their losses and taking over the costs of the most expensive cases, but that financial assistance ends in 2017. “As it’s fading out, it’s putting upward pressure on premiums,” said Evan Saltzman, an analyst at the RAND Corp.

James Capretta, a former George W. Bush administration budget official now at the American Enterprise Institute, said it will take several years of exchange experience for insurers to know  how much medical care their customers use —and if it matches what they expected.

“The biggest open issue is what the risk profile turns out to be,” Capretta said. “We’ll know more about that in 2016 and we’ll know even more about that in 2018.”

Star Ratings Coming 

While the exchange websites have mostly surmounted their early technical problems, they still lack key pieces of information about the quality of the various plans, which the health law required. The federal Department of Health and Human Services plans to require exchanges to display quality ratings for each plan, which will be represented by a five-star scale, in time for people buying their coverage for 2017.

To devise these ratings, the department this year is testing a satisfaction survey for consumers, asking people to rate on scales of 0 to 10 their health plan, personal doctor, specialists, ease of getting care and other aspects of their experience. The agency is also preparing to collect a few dozen measures of clinical quality. Many are rudimentary, such as whether children had a preventive care visit and whether adults received flu shots.

Government quality rating efforts elsewhere have shown how challenging it is to fairly differentiate between providers. A current effort to evaluate the medical care provided by large medical groups rated 85 percent of them as average. The government has been more discerning about private Medicare Advantage insurance plans, though regulators have been refining those scores since stars were first awarded in 2008. A third of plans were given four or more stars this year, and 4 percent earned 2 ½ stars or fewer.

“This has always been the big question about the ACA,” said Lanhee Chen, a researcher at the Hoover Institution. “Are people going to be able to make educated choices?”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Salt Lake City hairdresser Victor Saldivar said that getting subsidized health insurance under President Barack Obama’s health law saved his life after he was diagnosed with kidney cancer last June.

His health plan covered the removal of his cancerous kidney, for which he paid just $500. He’s been healthy ever since, although he must continue to get tested to make sure the cancer has not returned.

“I’m extremely relieved,” he said of the Supreme Court’s decision upholding the health law subsidies that have helped him and more than 6 million Americans purchase private health plans. “Without the subsidy, I am not sure what I was going to do. I was thinking of moving out of my apartment and go live in my car to afford coverage.”

Across the country, people who used the federal health insurance exchange to buy subsidized health insurance expressed relief about Thursday’s ruling in King v. Burwell. “I felt like I was out at the edge of a cliff,” said Steve Creswell, 63, of Hixson, Tenn., who feared the loss of his subsidy would have increased his insurance premium from $27 a month to over $400.

“It’s a lifesaver,” said the self-employed computer programmer. “Not just for me but for millions of others who needed this.”

Creswell, who was uninsured for a decade because he could not afford it, said that having coverage enabled him to see doctors to monitor his diabetes and to get his first colonoscopy.

Health experts say the loss of the subsidies would have left millions of Americans without the ability to afford coverage and many would have struggled to get timely care. “We would have seen real health consequences for many Americans,” said John Ayanian, director of the Institute for Healthcare Policy & Innovation at the University of Michigan

Studies show that when people lack coverage, they postpone getting care, which can increase their chances of having heart attacks, strokes and other major problems, he said.

Without insurance, many rely on community health centers and hospital emergency rooms —“better designed to care for people with acute medical problems than those with chronic problems,” he said.

“Oh yes, yes, that is such good news. I feel like I’m going to cry,” said Lisa Paterson, 60, of Moab, Utah.

Without a subsidy, her insurance cost would have increased from $26 a month to nearly $500 a month.  “I’m elated and happy for me and the millions of Americans [reliant on subsidies]. This is a reaffirmation of who are as a country.”

Paterson, a self-employed life coach who also tutors children in math and reading, said without her subsidy, she would not have been able to get insurance and would have had to rely on less expensive naturopaths for care of her diabetes and osteoporosis.

Having subsidized coverage enabled Barbara Clary, 61, a retired cafeteria worker and her husband, John, a writer, to get a policy for $100 a month. The insurance helped the Garland, Texas, couple afford surgery recently to remove a tumor on the back of John’s neck.

“The people won,” John Clary said. “I was a little bit worried because the Republicans had no backup plan.”

“Why would they want to take insurance away from us and all these people because of a little sentence in the law?” Barbara Clary asked. “We can’t afford to pay $300 or $400 a month for a premium.”

Jennifer Diefenbach, 39, of Fort Lauderdale, Fla., said she felt “an overwhelming sense of relief.”

“I don’t have to worry anymore whether or not my family will continue to have access to affordable health insurance,” she said. “But it is also bittersweet because logically, if we live in the great country I think it is, we shouldn’t even be arguing about universal healthcare … But we are, and we still will be in 2017, so I’ll continue to be vocal about something that helps my family, my community and millions of Americans.”

A self-employed proofreader, she pays about $70 a month for a health plan for herself and her husband, David, thanks to a subsidy. Without a subsidy, their monthly cost would be about $400—beyond what they can afford, she said. “Right now we are pretty healthy but it’s terrifying to not be able to keep our insurance,” she said, adding that her coverage enabled her to monitor her pre-diabetes.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Affordable Care Act survived its second Supreme Court test in three years, raising odds for its survival but by no means ending the legal and political assaults on it five years after it became law.

The 6-3 ruling stopped a challenge that would have erased subsidies in at least 34 states for individuals and families buying insurance through the federal government’s online marketplace. Such a result would have made coverage unaffordable for millions and created price spirals for those who kept their policies, many experts predicted.

Chief Justice John Roberts wrote the opinion for the court, joined by frequent swing vote Anthony Kennedy and the liberal justices Ruth Bader Ginsburg, Stephen Breyer, Sonya Sotomayor and Elana Kagen.

“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” wrote Roberts. “The combination of no tax credits and an ineffective coverage requirement could well push a State’s individual insurance market into a death spiral. It is implausible that Congress meant the Act to operate in this manner.”

Consumer advocates were hopeful for this outcome.

“The first thing going on for a huge swath of people is relief that we didn’t blow up the system,” said Lynn Quincy, a health policy specialist at Consumers Union. “The law was never meant to work without this pillar in there,” she said of the subsidies.

But even a victory for the law closely identified with President Barack Obama leaves the health system with incomplete insurance coverage, rising costs and other uncertainties. The ACA itself still faces several lawsuits, although some believe Thursday’s decision will discourage judges from advancing the cases.

“It sends a message to the lower courts that they need to take a good, hard look at all the ACA litigation that’s out there and probably clean up and get rid of most of it,” said Timothy Jost, a law professor at Washington and Lee University and an expert on the health law.

Kaiser Health News interviewed Jost and other authorities before Thursday’s decision in a case known as King v. Burwell asking them to explain the implications of upholding the law.

Republicans controlling Congress are likely to advance new legislation amending or repealing the law, although it is even more likely to be vetoed by President Barack Obama if it gets to his desk.

The high court decision sets up the 2016 presidential election as the health law’s next big test, although by then it could be difficult to fully uproot even if Republicans take the White House.

“With another year and a half of business as usual under the ACA, if it’s a Republican as the next president, it’ll be that much more difficult to make changes,” said Joseph Antos, a health care economist at the American Enterprise Institute.

The case hinged on tax credits created by Congress to help middle-income consumers buy insurance through online marketplaces, also known as exchanges.

The subsidies are available through an exchange “established by the state,” according to the law.

Thirty-four states did not set up their own exchanges and rely instead on healthcare.gov, run by the federal government. Lawyers for the plaintiffs argued that, as a result, millions of consumers in those states should not receive tax credits to pay premiums.

Pulling the subsidies would have undermined the insurance market in those states to the point of likely failure, experts said. Unable to afford the coverage, many consumers would have dropped out. Those remaining would probably have been older and sicker, driving up premiums to unsustainable levels.

Eighty-five percent of those who bought insurance through healthcare.gov qualified for subsidies averaging $272 per month. The Department of Health and Human Services predicted 6.4 million people would have lost subsidies if the court ruled for the plaintiffs.

Those subsidies are effectively revenue for hospitals and health insurers, financing premiums and the cost of care. Both industries are relieved they were upheld.

“Providers will feel better,” said Peter Strack, a consultant with the Altarum Institute, which works closely with hospitals. “They don’t have to worry about this back and forth of, ‘Will I have the appropriate population covered?’”

A loss for the administration would have affected employer-based coverage as well, although not nearly as much, benefits lawyers said.

For large employers not offering health insurance, penalties are triggered when workers obtain subsidies in the marketplaces. No subsidies, no penalties, so employers could have dropped coverage without fearing fines.

Although employers are focused on complicated, health-law reporting requirements that take effect this year, their situation changes little in the wake of the decision, said Edward Fensholt, a benefits lawyer with brokers Lockton Companies.

“The working assumption has been, ‘We need to offer this coverage to our full-time employees or we’re going to risk these penalties,’” he said. “And that’s not going to change.”

ACA supporters said the lack of a reference to tax credits for the federal exchange was a drafting error and that Congress intended for subsidies to be available regardless of the platform. Lawyers for the plaintiffs said the government must follow the letter of the law.

The health law faces other legal cases, including objections from religious institutions to their role in providing birth control coverage and a suit by the House of Representatives contending that Obama’s delay in requiring employers to offer coverage was illegal.

But even if legal challenges to the law disappear, health insurers, doctors and hospitals face broad uncertainty.

Signups for 2015 exchange coverage were lackluster. At the end of March, a little more than 10 million people had enrolled and paid for insurance, less than the 13 million the nonpartisan Congressional Budget Office was projecting last year.

Health costs seem to be creeping up again in a system that is already the most expensive in the world.

In recent years large, self-insured employers have seen health-spending increases of 4 or 5 percent a year, said Dale Yamamoto, an independent actuary who works closely with such companies. So far this year those companies are seeing 6 or 8 percent, he said.

“Everyone I’m talking to — it sounds like they’ve started to go up this year,” he said. “If it’s going up for them, it’s probably going up on the individual side as well.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Before the Affordable Care Act, older adults who couldn’t afford to buy their own health insurance would count the days until their 65th birthday, when Medicare would kick in. Now, 10,000 Americans hit that milestone every day, but for some who have coverage through the ACA’s insurance marketplaces, Medicare may not be the obvious next step.

“Consumers eligible for Medicare can keep or renew their marketplace plan,” said Medicare spokesman Alper Ozinal, as long as they don’t also join Medicare.

However, only a minority of those who have qualified for the health law subsidies that reduce their plans’ premium costs and cost-sharing will be able to keep that financial assistance once they become eligible for Medicare, Ozinal said. This option is available, he explained, only for people who would have to pay for Medicare Part A, the hospitalization benefit, but have not enrolled. That generally happens when seniors didn’t pay into Medicare for at least 10 years, which is sometimes the case for recent immigrants and people who may have come into the workforce late in their lives.

The majority of older adults — those eligible for free Part A coverage — cannot keep their subsidies when they qualify for Medicare, usually at age 65, according to an Internal Revenue Service spokesman.

Although seniors can pay full price to stay in their marketplace plans as long as they don’t enroll in Medicare, advocates say postponing the switch is   generally a bad idea. If they later decide to enroll, they will face late fees that will raise their premium costs, sometimes substantially.

Yet there are few guideposts to keep most consumers with marketplace insurance from making what could be an expensive mistake.  Except for people receiving  Social Security benefits before they turned 65, there’s  no reminder from the federal government or most state exchanges when it’s time to enroll in Medicare. There’s no warning to individual consumers when they become eligible for Medicare about the financial risks they could face if they don’t notify the marketplace and insurers to stop their subsidies. And there’s little help from the maze of conflicting marketplace and Medicare rules.

But there is a way to minimize the chance of problems, said Joe Baker, president of the Medicare Rights Center.

“The federal government should send a notice to everyone 64 years old saying you’re going to become eligible for Medicare at age 65 and here are your options, and some information about how to enroll, why to enroll and when you should enroll,” he said.

Determining whether marketplace coverage is better than Medicare depends very much on the individual, said Bonnie Burns, training and policy specialist for California Health Advocates, a nonprofit advocacy organization. For a small percentage of wealthy older adults, it may be cheaper to keep a marketplace plan rather than pay Medicare’s highest premiums for Part B, which covers outpatient care. But premiums should never be the only consideration, she said.

“It boils down to a comparison of benefits and costs,” Burns said. And that’s a difficult task since marketplace plans have different deductibles, cost-sharing, covered drugs and provider networks. Some plans restrict members to a limited number of providers, while traditional Medicare does not. And the calculation is also going to depend on whether you have chronic health conditions or if you are someone who doesn’t go to the doctor very often, she added.

Plus how much health care someone needs can also change over the years. In the final analysis, if someone is eligible for Medicare, Burns recommends signing up.

But whether they join Medicare or keep their marketplace policy, it is up to consumers to notify the marketplace and the insurer to stop the subsidies as soon as they qualify for Medicare. If they fail to do that and continue to receive subsidies after they became eligible for Medicare, they may have to repay that money when they file their taxes. If seniors with marketplace coverage also enroll in Medicare Part A, the government willeventuallycancel their marketplace plan if they don’t cancel it themselves.

Medicare rules established well before the marketplaces were created encourage people to sign up when they first become eligible — within the period from three months before and three months after their 65th birthday. People with job-based insurance or coverage through their spouse’s workplace, usually have until eight months after that insurance ends.

Enrolling later can result in penalties. People who would pay a monthly premium for Part A and sign up late may be charged an extra 10 percent in their premiums for  twice the number of years they could have had Part A but didn’t get it.

For Part B, beneficiaries may pay a 10 percent permanent penalty for every year they were late in signing up. Under some circumstances, there’s also a fee for postponing enrollment in a Medicare prescription drug plan.

“This is an area of great confusion,” said Burns. California Medicare counselors are reporting that people in marketplace plans are seeking help after their initial Medicare enrollment period has passed. “They didn’t understand the consequences of not signing up for Medicare,” she said.  “And some didn’t even know they should.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.