Four Words that could Deep-Six Obamacare: "established by the State"

The most serious challenge to President Obama's health care law since it survived the Supreme Court by a single vote in 2012 isn't a balky website, public opinion or the Republican takeover of Congress. It's the Supreme Court — again.

In a case likely to be heard in March and decided in June, the justices will dissect the meaning of four words on page 95 of the 906-page Patient Protection and Affordable Care Act — four words that could render health insurance premiums unaffordable for millions of Americans.

Obamacare's next round at the Supreme Court hinges on the 
meaning of four words in the 906-page law.(Photo: Eric Gay, AP)

Here's a look at the issues in King v. Burwell:

Question: Why the fuss over four words?

Answer: The law states that tax credits will be available through so-called exchanges, or online marketplaces, "established by the State." When it was being crafted, it was assumed that all 50 states would create their own exchanges. After it passed in March 2010, it became clear that many states would rely on the federal government to operate them, as the law allows.

In 2012, the Internal Revenue Service made the subsidies available in all states. The law's challengers claim they cannot be offered in exchanges operated by the federal government. Thirty-six states fit into that category. Without subsidies, insurance costs would skyrocket.

Q: What's more important — the plain meaning of those words, or the context?

A: That depends on whom you ask. The challengers say the plain meaning is clear: Subsidies can be offered only in state exchanges. If that's what Congress wrote, they say, the Supreme Court cannot change it, and the IRS cannot extend tax credits to federal exchange customers.

The administration and other proponents say the words must be read in the context of a law clearly intended to make health insurance more widely available and affordable. Even the suspect words appear in a subtitle of the law that reads, "Affordable Coverage Choices for All Americans."

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