This week, the U.S. Supreme Court will hear oral arguments in King v. Burwell, the case that threatens to undo a critical element of the Affordable Care Act. The Court will consider whether the subsidies that have allowed many to purchase health insurance were legally awarded to consumers using the ACA's federally run exchanges, and whether those subsidies should now be taken away. 

The ACA called for federal health insurance exchanges to fill the void left by states choosing not establish their own exchanges. This void was larger than expected, as only 14 states opted to operate their own insurance exchanges. Consequently, 8.84 million Americans have signed up for insurance via the federally run exchange, 

However, the provision calling for subsidies that would help make insurance affordable on the exchanges — the provision at issue in King — perhaps mistakenly limited those subsidies to “exchange[s] established by the state.” While other portions of the law suggest subsidies were intended to be available through state and federal exchanges, the challengers in King contend the law means what it says: subsidies are limited to state-run exchanges.

Georgia is one of the states that declined to establish an insurance exchange. Approximately 425,000 Georgians have purchased insurance through the federal exchange, 90 percent of whom receive subsidies. 

If the Supreme Court rules against the government in King, these half-million Georgians will lose their subsidies and face significantly heightened premiums. The effects of this change will likely be felt by anyone who holds private insurance in Georgia: unaffordable insurance means fewer insured, and fewer insured means higher premiums across the board

Such a ruling would reduce the financial support available to Georgians under the ACA to roughly zero, as the state has already rejected the law’s Medicaid expansion. From a practical standpoint, dismantling the law in such piecemeal fashion would continue to be highly problematic, given that much of the ACA would still impact Georgia. (For example, certain individuals and employers will still be mandated to purchase insurance.) 

The worst victim of this selective undoing of the ACA might be providers, as the law's reimbursement and disproportionate share cuts will remain in effect, but would not be offset by increased privately insured or Medicaid patients. Providers would also continue to bear the same amount of uncompensated care they did before the ACA. 

The Department of Health and Human Services has announced it is not pursuing a contingency plan in the event of an adverse ruling, though some Republican legislators have proposed alternatives to the law they have long maligned. The Court’s decision is expected in late June.