WASHINGTON

A case about four words, with mammoth implications

Richard Wolf
USA TODAY
The U.S. Supreme Court will hear oral arguments March 4, 2015, on King v. Burwell.

WASHINGTON — President Obama's health care law squeaked through the Senate in 2009, the House in 2010 and the Supreme Court in 2012. Wednesday, the high court will consider whether it can survive its infancy.

The case is far narrower than the one brought — and nearly won — by opponents three years ago. Opponents of the law claim it allows health insurance premiums to be subsidized only in states that set up exchanges, or online marketplaces. If the court agrees, those subsidies can't continue to flow to residents in at least 34 states that use a federally operated exchange.

It boils down to a fight over four words in the law: "established by the state." But its implications are mammoth to those with the most at stake:

• Tax credits enjoyed by more than 9 million people could be lost if the justices agree with the law's opponents. That would make health insurance unaffordable for most of them. The subsidies are available to individuals and families with income up to 400% of the federal poverty level, or $97,000 for a family of four.

• The law's individual and employer mandates would apply to fewer people if the subsidies are struck down. Insurance premiums would cost millions of families more than 8% of their annual income, entitling them to an exemption from the law's mandate that most individuals buy insurance. Many employers, too, would be freed from having to provide coverage if none of their employees was subsidized.

• Insurance premiums would rise for those remaining under Obamacare as millions drop out of the market. Many of those remaining would be older and sicker people who require coverage. The average annual premium for people in states using the federal exchange would rise by an estimated 35%, according to the Urban Institute and the Robert Wood Johnson Foundation.

• President Obama would see the crowning achievement of his administration crippled. His administration would be pressured to come up with an alternative to salvage the law. Without a fix, his legacy in the area of domestic policy would be tarnished.

• Congress would be pressured to devise a solution for the millions of Americans whose health insurance is put at risk. Moderate Republicans in the Senate have proposed a fallback plan, but it lacks support from conservatives and Democrats.

• Governors and legislatures in the 34 states that do not operate their own health insurance exchange and have no timetable to do so would be under the gun to create a state exchange — something that requires money, technology and political will.

• The Supreme Court's reputation is on the line, as Chief Justice John Roberts no doubt realized in 2012 when he rescued the health care law by equating penalties for not buying insurance with a tax that Congress had the power to levy. If opponents win the case, it most likely will be on a 5-4 vote, all five votes coming from justices nominated by Republican presidents.