Implications of King v Burwell on American Healthcare


~ by Dr Irv Loh

When I wrote my post earlier this year around the health implications of the State of the Union speech, I intimated that King v. Burwell was going to be a really big deal when the Supreme Court finally ruled.  The case was based on four words that could have eventually determined the fate of up to 20 million Americans.  Those words…”established by the state”.  And the even more paradoxic fact is that the plaintiff, Mr. David King, was not even affected by the outcome since, as a Vietnam vet, he gets his healthcare from the VA, not the Affordable Care Act, colloquially (and derisively) referred to as ObamaCare.

If the Supreme Court had found for the plaintiff, over 6 million citizens immediately, and as many as 20 million citizens eventually, in the 36 states that did not build their own insurance exchanges due to technical or political reasons may have had their health insurance subsidies disallowed.  These states deferred to the federally established to barter their state’s insurance options.  14 states and the District of Columbia built their own exchanges.

To review, the issue was that the subsidies that make the health insurance affordable are, by law, allowed for those individuals who enrolled “through an Exchange established by the State under 1311″ — which is the section that set up state-based exchanges.  If the Supreme Court had found for the plaintiffs, and if there is no state-based exchange where a citizen lived, those people would have been ineligible for subsidies, effectively making their health insurance unaffordable.  And the premiums are high enough as it is.  During the writing of the legislation, even Republicans noted that there was no distinction made between state or federal exchanges, with the latter being the backstop if states did not create their own.

Politicians can and will celebrate or rail against the Supreme Court decision depending on which side of the very polarized spectrum one resides, but that is a disembodied concept without a human face.  Patients of mine know that I often discuss how economists and politicians can dissect out healthcare arguments for or against anything, as long it’s an abstract concept without faces…or as I say, “unless it’s their mother”.

The argument hinged on a literal translation of the meaning, or a contextual interpretation of the intent, of the Affordable Care Act.  The liberal position was that the government should do what it can for those who have no ability to afford healthcare and suffer the subsequent consequences.  The conservative position was that taxes and regulations should not be used to provide subsidized healthcare for millions.  Unless it’s their mother.  So it became an argument of what they said vs what they meant.  And the Supreme Court in a 6-3 decision said the latter.

Those of we physicians who care for an insured population often have a different perspective than those who care for previously uninsured (due to socio-economics or prior condition exclusions).  The millions of Americans who now will continue to have access to vaccinations for their children, preventive care for themselves, or who can now walk in the front door of a hospital rather than only through the Emergency Room can appreciate what the ACA has meant.

So now what?  Is this all over?  Hardly.  This 6-3 decision in favor of the Affordable Care Act may make healthcare reform another hot potato in the looming presidential campaign, more so for conservatives who may make their Republican candidates’ position on keeping or dropping healthcare coverage through the Affordable Care Act a litmus test for support.  The American electorate at large will decide.



Irv Loh MDDr. Irving Kent Loh MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.

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