The Affordable Care Act is once again before the Supreme Court.  This time it’s not about whether the government can force you to have health insurance or pay a penalty.  It can. That is so “2012.”

Now, in the case of King v. Burwell, the meaning of six words in a thousand-page law is under scrutiny. Those words could determine whether millions of Americans can afford to buy health insurance.

The law states that people who sign up for health coverage through “an exchange established by the state” qualify for government subsidies.

But what is an exchange established by the state, you ask.

The Obama administration says it’s every insurance marketplace set up by a government. That includes the federal government’s healthcare.gov. It’s used by the residents of about three dozen states.

But the lawsuit argues it’s only the 16 states and the District of Columbia that set up their own marketplaces.

If the challengers win, more than 6 million Americans would lose the subsidies that have helped them afford health insurance.  So, if you bought your policy through healthcare.gov – the federal exchange – you would no longer receive that help.

What does this mean for the health insurance system? Healthier people would likely drop coverage if they lose financial help, which means insurers would raise premiums because they would be covering fewer, but sicker people. That would impact everyone who buys their own insurance in those states.

Of course, Congress could step in to clarify the confusing words. But many think that’s unlikely.  Or some states might decide to create their own state-based insurance marketplaces. But that couldn’t happen overnight.

The justices are expected to deliver their decision in late June, just as the 2016 presidential campaign is kicking into high gear. So keep your eyes and ears open because this decision could affect you.

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

Nurse practitioner Martha Brinsko helps a lot of patients manage their diabetes at the Charlotte Community Health Clinic in North Carolina.

“Most mornings when you check your sugar, what would you say kind of the average is?” Brinsko asked patient Diana Coble.

Coble hesitated before explaining she ran out of the supplies she needs to check her blood sugar levels, and she didn’t have the gas money to get back to the clinic sooner. Brinsko helped Coble stock up again.

“If you need to get more than one box, get more than one box,” Brinsko said. “But you need to check them every morning so that we can adjust things.”

Coble, who is unemployed, lives with her sister and can’t afford insurance even now that the health law is in place, relies on the clinic for health care.

“They do a great job with everything,” Coble said. “I couldn’t do without them.”

Nancy Hudson was the clinic’s director as Obamacare rolled out and now consults for the clinic. She expected the insurance exchange, or marketplace, established under the Affordable Care Act would reduce the number of patients like Coble. The opposite happened, she says.

“What we found within our patient population and within the community is that a lot of the advertisement and information about the marketplace brought people [in who] didn’t know anything about free clinics and did not qualify for any of the programs within the ACA marketplace,” Hudson says.

And now they get free or low-cost care at the clinic, which is designated by the government at an FQHC, or federally qualified health center.

The health law was designed to cover the poorest people by expanding Medicaid, the federal-state program for low-income people. But the Supreme Court made that optional. The result in states that didn’t expand Medicaid is a gap, where some people make too much money to qualify for Medicaid but not enough to qualify for insurance subsidies. In North Carolina, about 319,000 people, like Coble, fall into the Medicaid gap.

“Over half of the people that we see would’ve been eligible for Medicaid expansion had the state elected to exercise that option,” says Ben Money is president of the association that represents North Carolina’s community health centers.

North Carolina is among the 21 states, including many in the South, that are currently saying no to Medicaid expansion. Louisiana is another.

Dr. Gary Wiltz, the CEO of 10 community health centers in the southwestern part of Louisiana, says demand has surged. “We’ve gone from 10,000 patients to 20,000 in the last six or seven years, so we’ve doubled,” he says.

Wiltz says other things are at play, too. The economic recovery hasn’t reached many of the poorest people, and some who do qualify for Obamacare subsidies say their options are still too expensive.

“The need keeps increasing, and I think that’s reflected throughout all the states,” he says.

Wiltz, who also heads the board of directors for the National Association of Community Health Centers, says clinics are packed even in states that expanded Medicaid. After all, most of the clinics treat Medicaid patients too.

The Charlotte clinic’s Nancy Hudson says there’s another part of the health law helping fuel the growth: additional funding for community health centers.

Hudson found out last week her clinic is getting about $700,000 to expand in partnership with Goodwill.

“Many of their clients did not have any access to health care,” she says. “They can’t train and sustain a job if they don’t have the basic needs taken care of, and health care is one of them.”

Nationwide, the federal government estimates its latest round of funding will lead to about 650,000 people getting better access to health care.

This story is part of a reporting partnership with NPR, WFAE and Kaiser Health News.

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

More than 1.3 million Florida residents — the most of any state — could lose their financial aid for health plans under the Affordable Care Act if the Supreme Court rules against the federal distribution of subsidies later this month.

New data released Tuesday by federal health officials in advance of the decision showed that Florida, which enrolled the most people in Obamacare, also stands to lose the most.

Those Floridians received an average subsidy of $294 a month in March to reduce their premiums, according to the new data. Among those Floridians, nearly 1 million also received financial aid from the government to reduce their out-of-pocket costs, such as co-payments, co-insurance and deductibles.

That means Floridians received at least $389 million in March from the federal government to help pay for their health insurance.

The subsidies are at the center of a Supreme Court case challenging the health law. In King v. Burwell, the plaintiffs argue that the language of the health law restricts the subsidies to states that established their own exchanges.

Leah Barber-Heinz, chief executive of Florida CHAIN, a nonprofit consumer health advocate in favor of the health law, said the Sunshine State risks more than financial assistance for low- and moderate-income residents to buy health insurance.

“Lives are at stake when the courts rule on cases like King v. Burwell,’’ she said in a written statement. “When a million people lose their health insurance, some of them will face dire consequences.”

A total of 34 states, including Florida, rely entirely on the federal insurance exchange and risk losing subsidies if the Supreme Court rules against the health law. Through March, those states enrolled a total of about 7.3 million Americans, of which 6.4 million receive an average government subsidy of $272 a month to lower their premiums.

The data released by the Department of Health and Human Services reported that an estimated 10.2 million Americans, including about 2.9 million who enrolled through state-based exchanges, had paid for their Obamacare health plans as of March 31.

That’s a reduction from the total 11.7 million sign-ups reported earlier this year. Still, HHS Secretary Sylvia Burwell said in a written statement that the insurance exchanges are “working.’’

“We’ve seen a historic reduction in the uninsured and consumers are finding the coverage they need at a price they can afford,’’ Burwell said.

Critics of the health law, however, insist Obamacare is not working.

Andres Malave, a spokesman for the Florida chapter of Americans for Prosperity, a conservative group that opposes the ACA, accused the Obama administration of creating uncertainty and angst among Floridians.

“It’s legitimate anxiety that the Affordable Care Act has caused,” Malave said. “And it’s forcing Floridians to unfortunately have to live in a world where they are unsure of how their coverage is going to be affected because the president’s administration decided that a big government solution was better for Floridians instead of allowing the free market to operate.”

Of the 10.2 million Americans with effective coverage in March, 85 percent or about 8.7 million were receiving subsidies.

In Florida, about 1.4 million residents were enrolled in and paying for health plans through March 31, according to the data, and more than 93 percent — or about 1.3 million people — were receiving a government subsidy to help pay for the insurance. Florida had the second-highest rate of consumers, after Mississippi, who received financial aid to pay for their premiums in March.

According to federal data, Florida residents who received a government subsidy to make their health plan more affordable paid an average premium of $82 in February — well below the national average of $101 a month.

If the Supreme Court ends subsidies, Floridians receiving financial aid would face an average premium increase of 359 percent, according to a new analysis by the Kaiser Family Foundation, a nonprofit health policy research group. (KHN is an editorially independent program of the foundation.)

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

Worried about going without health coverage, musician Tom Miller bought a nine-month insurance policy in January to tide himself over while he rebuilt his business after a divorce and moved from Maryland to North Carolina.

At $90 a month, it fit his budget, even though it does not offer the broad benefits required by the federal health care law.

Long seen as a stopgap for people between jobs, short-term policies that focus on catastrophic coverage can fill a niche for people like Miller looking for protection against unforeseen accidents, say some insurance brokers.  In exchange for their lower premiums, the plans come with sharp limits, including no coverage for pre-existing medical conditions. Many consumer advocates hoped interest in such plans would decline after the Affordable Care Act made broader coverage widely available, but short-term policies appear to be enjoying a resurgence, brokers say.

“We’re writing more short-term now than before the ACA,” although not as much as in the boom years of the early 1990s, said Lynda Sussman, owner of C.O.B. brokerage, which sells insurance policies through its office in Pikesville, a suburb of Baltimore.

The plans attract not only those between jobs, but also people who missed the deadline to sign up for an ACA policy and those who say they can’t afford a more comprehensive plan, she said.

One of the nation’s biggest online brokers — eHealth — has also seen a surge in consumer demand. The website reports that applications for the policies on its website rose 130 percent, to more than 140,000, between 2013 and last year, when the ACA’s requirement that most Americans carry insurance went into effect.  The eHealth website may not necessarily reflect national trends, but little data exists from government or industry sources on the sales of short-term policies.

When he bought his plan online from eHealth, Miller said he didn’t know that it would not protect him from a tax penalty of at least $325 imposed by the federal health law for failing to have coverage that meets the law’s minimum standards.

“That bothers me,” said Miller, 36, a self-employed sound engineer and drummer in Raleigh, who formerly had coverage through his wife and now may face at least a $325 penalty for not having coverage this year. “I should still qualify.”

On the eHealth website, consumers can see disclaimers for the short-term plans, warning, “even if you enroll in and maintain short-term coverage, you may still be subject to the tax penalty.” Short-term policies, which can be bought in increments of 30 days to 12 months, generally have lower premiums than other health insurance. While that is attractive to many consumers, the premium price reflects their limits: They are exempt from most provisions of the health law.

Applicants, for example, can be rejected for coverage if they take prescription medications or have a health condition, which the federal law prohibits for other types of insurance.  EHealth reports that insurers turned down 18,000 short-term policy applicants using its website last year, up from 5,500 in 2013.  The plans usually ask applicants a few simple questions about their health, but could seek more information from a policyholder’s medical records.

In addition, short-term policies rarely cover maternity care, some cap the dollar amount of care they will cover, they can’t be renewed and any medical conditions policyholders develop during the course of the policy can be excluded from coverage if they do re-apply.

“People are really taking a chance,” said Karen Pollitz, who studies the insurance market as a senior fellow at the Kaiser Family Foundation. “They have to hope they stay healthy until the next open enrollment.” (KHN is an editorially independent program of the foundation.)

For Miller and others, the draw is the price.  He could have stayed on his wife’s policy for a time while going through his divorce, but it would have cost $300 a month.
“That’s a car payment,” he said. “I didn’t want to put myself in a financial situation with more stress.”

EHealth reports the average premium nationally for a short-term policy is about $110 a month for an individual, and carries an average annual deductible of $3,589.  They’re less expensive for younger people, averaging $89 a month for those between the ages of 25 and 34, the biggest group applying for coverage through eHealth. No subsidies are available to help people purchase them because they don’t qualify as ACA plans.

Premiums are generally higher for coverage that meets the requirements of the federal health law. A Kaiser Heath News analysis of 2015 rates found the average monthly premium for a 40-year-old buying the lowest cost silver-level coverage through the federal online market nationally was $273, before subsidies. Still, federal data show that 87 percent of those enrolling through the federal website received subsidies of varying amounts to help offset the premium cost.

Brokers say that some of those purchasing coverage are doing so because they fall into the “coverage gap,” earning too much to qualify for Medicaid coverage in states that did not expand eligibility, but too little to get a subsidy.

Ruth Dunlap, a 36-year-old office assistant in Ann Arbor, Mich., said she bought a policy this spring, hoping it would protect her until she can get a full-time job with benefits.  She works temporary jobs, earning between $10,000 and $20,000 a year.  She signed up for the short-term policy after she was told she earned too little to qualify for a subsidy in her state, and her state did not expand Medicaid eligibility under the health law until April.

Not long after getting her policy, Dunlap went to the emergency room with a gall bladder attack.  The hospital sent a bill for $1,500  — marked down from $2,000 because she had insurance – but she hasn’t yet submitted the paperwork to the insurer to see how much of the bill will be covered by her $75-a-month plan. She’s likely to have to pay a deductible first, but isn’t sure of the amount. She may also face questions from the insurer about whether she had any past gall bladder problems and might get no help if she did.

Last week, Dunlap learned she may now   qualify for Medicaid since the state expanded eligibility to those earning up to 133 percent of the federal poverty level, about $16,000 for a single person.  She applied and is waiting to hear if she’s been accepted, but will hang on to her short-term policy in the meantime.

Many people won’t qualify for a short-term policy, particularly if they have had a recent illness or are taking certain medications. Broker Sussman said she does not recommend short-term plans for older customers, or those with health conditions. Still, for some clients, particularly younger adults being pushed to have coverage or those who missed the open enrollment deadline for the ACA and just want something in place until the next enrollment period in the fall, “it’s better than going without and it’s a helluva lot cheaper” than other types of insurance, she said.

Not every broker agrees the policies are worth having.

“I refuse to sell it to someone in lieu of Obamacare,” said Susan Lundy of Benefits by Design, a brokerage in Larkspur, California.  She said the main reason customers ask about the plans is their price, but she warns them that the policies won’t cover any existing medical conditions. And if something happens during their term, “if you break your leg and you get a new policy six months later, they have an exclusion on the break,” she said.

Lundy said even people who fear they’ve missed the ACA signup enrollment period, which this year ran from mid-November until the end of April, may not be out of luck.

Many people can qualify to buy a plan now through a number of exceptions, which include losing other ACA-qualified coverage, moving, getting married or having a baby.

Because he recently moved and lost his coverage when he divorced, Miller might qualify. For now, though, he’s hanging onto his short-term policy while looking around do see what else is available.

“I know I need health insurance,” Miller said. “I travel a lot. I’m active. The policy is good while I go through a transition. I just needed something until I get my feet back on the ground.”

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

LOS ANGELES — Will Nebbitt lives on the 5th floor of a new downtown apartment building. From his window, he has a panoramic view of the Los Angeles skyline. He can also see Skid Row, where he spent decades sleeping on the ground.

Nebbitt, 58, says his body can’t handle life outside anymore. He has a seizure disorder, heart disease and depression. He’s had four operations, including bypass surgery on his leg in March.

“I am too old and sick to be back out there on the streets,” he said. “It kind of takes a toll on a person.”

Health officials handpicked him and about 100 other ill homeless residents to live in the Star Apartments, a sleek white building with a medical clinic on the bottom floor. The apartments are part of a multimillion dollar experiment: Using county health care dollars to house people who are chronically homeless.

“If we don’t, they tend to die young on the streets,” said Marc Trotz, director of the Housing for Health program in Los Angeles County, which officially began in 2012. “And they just continually recycle through expensive health care settings.”

Now, California wants to take the approach statewide. It is asking the federal government for permission to use Medicaid money to help put the most medically fragile homeless people in housing.

Mari Cantwell, deputy director of the state health care services department, said health care and housing traditionally have been in distinct silos. “We are really trying to look at the whole person,” she said. “And our belief is that this will improve health care and reduce costs.”

Under the Affordable Care Act, hundreds of thousands of homeless residents who previously didn’t qualify for government health insurance became eligible for Medicaid. Federal health officials suddenly became responsible for many people with longstanding illnesses, including mental disorders and substance abuse. Realizing the potential costs, they began considering different ways to help patients without overburdening taxpayers.

Selling the federal government on California’s idea won’t necessarily be easy. The Centers for Medicare and Medicaid Services turned down a request from New York to house chronically ill homeless patients, saying it isn’t in the business of paying rent. New York now pays for such housing with state Medicaid funds. Other states,including Massachusetts and Louisiana, are using federal dollars not for rent but for services that keep specific populations, such as those with severe mental illness, in housing.

California’s proposal could be the most comprehensive of its kind, allowing Medicaid to cover a broader population on a consistent basis. The federal money would pay for case managers to help people get whatever they need to stay in housing except for rent – including transportation, job assistance and substance abuse treatment. Any savings could be used by managed care companies to invest directly in providing housing, in partnership with local governments and others. California does not yet have estimates on how much federal money it might need.

Carol Wilkins, a consultant and author of a recent report on “supportive housing” for the U.S. Department of Health and Human Services, said counties don’t have the resources to continue doing these projects on their own.  Medicaid needs to step in and recognize housing-related services as health care costs, she said.

But critics say Medicaid money is limited and should only pay for health care. “Saying you want to provide housing benefits out of Medicaid money is in my mind a stretch,” said Lanhee Chen, a research fellow at Stanford University’s Hoover Institution. “I think we have to draw the line somewhere.”

Click to view slideshow.

Studies in several states, including Illinois and Oregon, have shown a reduction in emergency department use and length of hospital stays when homeless people move into housing. Research on the Los Angeles County program produced similar results. In one 2013 report, the Economic Roundtable found that total health care costs for homeless patients in supportive housing  were 72 percent lower per person  than for those still homeless.

Through case management, recruitment and rent subsidies, the Los Angeles County Department of Health Services is helping house 700 people at dozens of sites and it plans to serve 1,500 more over the next year. Still, that is a fraction of the estimated 12,000 chronically homeless people in the county, and Trotz said federal Medicaid dollars would allow him to expand further.

Getting away from the chaos and temptations of the streets and settling in an apartment enables people to begin recovering from whatever led them to become homeless at the start, Trotz said. “It is really difficult or impossible to do that while living on the streets.”

At the Star Apartments, owned by the Skid Row Housing Trust, residents meet regularly with case managers. They can attend depression support groups and diabetes classes, plant vegetables in a patio garden or play drums in a music jam session. The apartments aren’t fancy – just about 350-square feet, with basic furniture, a small kitchen and a bathroom. But residents like having a space of their own.

Click to view slideshow.

“I’m just thankful that I have a place to go home to,” said Michael Montana, as he waited for a regular blood pressure check at the on-site health clinic, run by the county.

Montana, 59, who has a raspy laugh and gets around in a wheelchair, moved into the Star Apartments after about eight years on the streets and multiple trips to the hospital. Though he suffers from chronic lung disease, diabetes and arthritis, Montana said he hasn’t been to the hospital once in the last year.

Since moving in in late 2013, Nebbitt said his health is better, too. Standing just over five feet tall and wearing red-rimmed glasses, Nebbitt said he spends his free time reading the Bible and watching Divorce Court in his room.

When he was living out of a tent, Nebbitt didn’t have a place to put medications. He couldn’t kick an addiction to crack cocaine. He also didn’t have a regular doctor.

Now, he said, “I can just take the elevator five stories down and I am at my doctor’s office,” he said. “I can’t beat that.”

On a recent morning, nurse practitioner Lynda Stack saw Nebbitt, ordered some blood work and checked the scars from his bypass surgery. She also went through his health history, dating to when he was a child and started having seizures.

“I tell my patients we’re gonna have a long-term relationship,” she told him.

Click to view slideshow.

“Well, I’m in it for the long haul,” Nebbitt responded, smiling.

Sony Ta, the medical director of Housing for Health, said homeless patients don’t prioritize their health, often losing their prescriptions and missing appointments. Ta said giving them supportive housing makes far more of a difference than prescribing more medications.

The challenges are on full display just steps from the Star Apartments. As evening fell on a recent day, businesses began closing up and downtown’s hundreds of homeless returned to their spots, setting up tents and cardboard boxes.

A former construction worker from Orange County who became homeless just a few months earlier said he had cirrhosis of the liver. Another man with deep wrinkles and bright blue eyes said he’d had two heart attacks and worried about having a third if he didn’t get into an apartment soon. He’d been on the streets 10 years.

Nebbitt said he is glad not to have that life any more, and to be away from the danger and the cold.

“It’s my sanctuary,” he said of his apartment. “It’s like going from hell to heaven.”

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