Subsidies in federally run health exchange will live to see another open enrollment.

In an opinion penned by Chief Justice John Roberts, the Supreme Court ruled 6-3 that the Affordable Care Act's authors clearly intended to extend subsidies to people buying coverage through federally facilitated and state-run health exchanges.

With King v. Burwell resolved, the ACA might have faced its last major court challenge. Other parts of the law will face legal scrutiny.

But major threats remains to the exchanges and the law itself. Some are rooted in the laws structure and some are political, yet all could stall or wipe out the ACA. Even if the exchanges have been pushed back from the brink, the marketplaces aren't out of the woods.

State-run exchanges struggle for viability.

With Hawaii moving to and New Mexico opting to stick with for its technology, we're down to 12 states and Washington D.C. that built and run their own exchanges.

State exchanges from Rhode Island to Minnesota to California are facing budget deficits and are not enrolling enough people for insurance fees to make them self-sustaining.

Even successful, well-run exchanges face threats. In Kentucky, Gov. Steve Beshear established Kynect and Medicaid expansion with an executive order. The Republican candidate for governor, businessman Matt Bevin, has vowed to repeal both, which he could do with another executive order.

Aside from Access Health CT, Connecticuts exchange, state-run exchanges still face some level of existential threat. These struggles could lead to become even more of a national exchange.

The end of federal funding for risk-sharing in exchanges also represents a threat. Given the losses insurers have seen in the first two years of exchange coverage, some could flee if risk protection evaporates. However, don't be surprised if the insurance lobby finds some avenue to extend the corridors.

CO-OP collapse:

One CO-OP has failed. No reasonable person expects it will be the last. CO-OPs are using CoOportunity Health's rapid rise and fall as a cautionary tale. In 2015, the nonprofit plans created by the ACA cut premiums significantly in many markets, leading to drastic enrollment growth. The Tennessee CO-OP, Community Health Alliance, saw growth in high-utilizing swelling and suspended enrollment, while the Kentucky Health Cooperative delayed its expansion into West Virginia.

As with state-run exchanges, everyone will monitor CO-OPs for sustainability, mindful that at first glance, CoOportunity Health looked like a winner. But more will fall in the next few years.

Medicaid expansion still option.

The Supreme Court ruled the ACA and its mandates were constitutional in 2012. A second part of that ruling made Medicaid expansion optional. Most of the Southeast, including Florida and Texas, quickly opted out. Because the law did not include any provision people below the poverty level to receive exchange subsidies, they are effectively shut out of the market.

Why not simply open exchange enrollment to those below 100 percent of the federal poverty level? Because nothing with the ACA is simple and nearly everything related to it is politically charged. Any change perceived as aiding the law is anathema to Republicans.

The private option originally adopted by Arkansas spread only to a few states. Arkansas allowed its Medicaid expansion population to buy heavily subsidized exchange policies.

The fight in Florida over low-income pool funding for hospitals illustrates the depths to which opponents have dug in. With states picking a small share of the Medicaid expansion costs in 2017, new adoptees seem less likely all the time.
States with the coverage gap will see uncompensated care place additional pressures on premiums, and more rural hospitals will be forced to close.

The next president's role.

Even as the ACA becomes more embedded with how people buy health insurance, it could go away with a new president's signature in 2017. With every Republican candidate vowing to repeal the ACA and some proposing alternatives, the issue won't die down.

Reality of expanded coverage for tens of millions could set for an incoming Republican president. There would be intense pressure for a replacement, despite the great number of nebulous plans proposed. Better yet, it might lead to some of the reforms that even ardent supporters concede the ACA needs.

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