In the final week of the Supreme Court's recent session, Chief Justice John Roberts and four other jurists upheld the constitutionality of the Affordable Care Act
–widely known as Obamacare–including the contested individual mandate that requires consumers to purchase health insurance or face a penalty.
The justices, however, did give states the right to opt out of a critical provision requiring the expansion of Medicaid programs for the poor and disabled. A majority of the justices voted that the government could not compel states to expand Medicaid by threatening to withhold federal money for existing Medicaid programs.
Rob McKenna, Washington's attorney general and a candidate for governor, was one of 26 state officials–all Republicans–who brought the case to the high court. Following the ruling, however, McKenna expressed resignation to the court's decision and said Washington would begin work to implement the health care exchanges and Medicaid expansion provisions of the legislation.
"There are a number of good provisions in this law that ought to be maintained," McKenna said at a news conference following the court's ruling.
While some of the key features of ACA don't kick in until 2014, the law has already altered the health care industry and established a number of consumer benefits.
For example, most plans now ban lifetime coverage limits and include a guarantee that an adult child up to age 26 who can't get health insurance at a job can stay on the parents' health plan.
Other parts of the law that are already in place include preventive services with no out-of-pocket costs, such as breast cancer screenings and cholesterol tests. Health insurance companies can't cancel your coverage once you get sick - a practice known as "rescission" - unless you committed fraud when you applied for coverage. Children with pre-existing conditions cannot be denied coverage, a feature that will be expanded to include adults in 2014.
Julie Vess, executive director of Safe Harbor Free Clinic
in Stanwood, applauded the court's decision but has lingering concerns about the real-life benefits of the legislation.
"If the state adopts the Medicaid expansion, some of our patients will be eligible for that program, but the problem exists in our area for access," said Vess. "Many providers/clinics have elected not to accept Medicaid patients due to very low reimbursement rates. So even though some patients will have insurance, they may have a difficult time finding a provider that will accept that insurance."
The Safe Harbor board of directors has decided that the clinic will better serve the community by caring for the uninsured and underinsured while referring patients who qualify for Medicaid to community health centers like SeaMar
, Community Health Center
or the Providence Clinic
"Many of our patients will not qualify for Medicaid but will not be able to afford the insurance through the healthcare exchange," Vess continued. "Or they will purchase the insurance through the exchange or their employer but then will not have the means to cover the deductibles, co-pays and co-insurance."
Low-income residents will likely benefit from expanded Medicaid coverage in Washington. Residents with an income up to 133 percent of the federal poverty level – $14,856 for an individual or $30,656 for a family of four – may qualify for the federal program even if there are no children in the household.
Government subsidies to help families afford health insurance start at the same threshold, 133 percent of poverty level, and are available for those earning up to 400 percent of the poverty level, which is currently $30,656 for an individual or $92,200 for a family of four.
And that penalty or tax that will be levied if individuals who can afford it opt not to purchase insurance? In 2014 the fine is set at $95 or up to 1 percent of income, whichever is greater. By 2016 the penalty will climb to $695 or 2.5 percent of income.
The National Federation of Independent Business
(NFIB) was also a plaintiff in the Supreme Court case, arguing that the health care legislation would impose a hardship on small businesses.
Under the law, no employer is required to provide insurance
. But starting in 2014, businesses with 50 or more employees that don't provide health care coverage and have at least one full-time worker who receives subsidized coverage in the health insurance exchange will have to pay a fee of $2,000 per full-time employee. The firm's first 30 workers would be excluded from the fee.
However, a firm with fewer than 50 employees won't face any penalties.
In addition, the health law offers a tax credit for small business owners to help cover the cost. Employers with 25 or fewer full-time workers who earn an average yearly salary of $50,000 or less today can get tax credits of up 35 percent of the cost of premiums. The credit increases to 50 percent in 2014.
Vess believes many people will still find themselves without health care coverage, making the continued presence of free or low-cost health care a priority.
"We have many consultants looking at the law both at the state and federal level at the free clinic associations, and it is predicted that 23 million Americans will still lack insurance even after full implementation in 2015," she said.
"Daily, our patients express their concern over the accessibility and affordability of health care," Vess continued. "We remain hopeful that one day health care will be more than a dream for those who need it the most."