For these families, King v. Burwell is more than a Supreme Court case

Before last year, if Jumaane Cook had a medical problem, he headed for the emergency room.

The Cleveland single dad, whose son is in kindergarten, says that after he seriously injured his knee playing basketball in 2007, he racked up $15,000 in emergency-room medical bills.

In 2014, Mr. Cook says he was able to get health insurance for the first time in his adult life – a bronze plan with a $5,000 deductible from a Kaiser HMO that covers him and his son for a premium of about $200 a month. Cook, a property and casualty insurance salesman, pays $70 per month after qualifying for a $120 subsidy through the federally run online marketplace.

Cook says he was “in shock” when he saw he could now get his own insurance. 

“I’m one of those Americans who, you know, they go to the emergency room when something happens, and then can’t afford those bills,” he says, noting he is still paying medical bills from 2007.

Cook says the experience has turned him into a political activist. And on Wednesday morning at 8:45 a.m., he says he will be standing outside the Supreme Court. 

On Wednesday, the Supreme Court is set to hear oral argument about six words within the 961 pages of the Affordable Care Act – six words that the plaintiffs say renders the federal subsidies – those offered to lower-income residents living in the 34 states who use the federal exchange – essentially illegal. Those words are "an exchange established by the state."  The justices will be hearing evidence on whether the IRS overstepped its authority when it set up a federal online marketplace for residents in states that opted not to create their own exchanges.

“I just don’t think they understand the impact that this has on people’s lives,” Cook says. “This will have a huge impact on myself, a huge impact on my life, on my family, and I just don’t think they fully grasp what exactly might happen.”

The Supreme Court's ruling could potentially invalidate the Affordable Care Act’s (ACA) subsidies for low-income Americans in 34 states, including Ohio, served by the federal exchange. If that happens, economists have warned, it could implode the 2010 health-care law popularly known as Obamacare.

The ACA has been controversial since its passing, as can be seen by the Republican-led House voting more than 50 times to undermine or repeal the health-care law over the past four years. The law also barely survived a challenge to its individual mandate provision, which requires all Americans to purchase health care, in a 5-to-4 Supreme Court decision in 2012.

And while 87 percent of those who have joined the insurance rolls through Obamacare currently receive an average $268-a-month subsidy, many Americans who do not qualify have seen their insurance premiums increase sharply. While most silver plans offered on the federal exchanges have only seen average increases of about 2 percent, areas in Alaska and Minnesota, for example, have seen steep increases, according to an analysis by the Kaiser Family Foundation.

But this year’s challenge, if successful, would mean that an estimated 9.3 million Americans in these states would lose their subsidies, according to a January study by the Urban Institute, an economic and social policy think tank in Washington, D.C. And the vast majority of these people – including, he says, Cook – would again become uninsured.

“In these 34 states, the number of uninsured would increase 44 percent, from 18.4 million to 26.6 million,” says Linda Blumberg, senior fellow at the Urban Institute’s Health Policy Center, and one of the authors of the study. 

Maggie Boyraz, an adjunct professor at St. Peter’s University in Jersey City, N.J., and mother of two, says that her family also would lose their health coverage if the federal subsidies go away.

“For families like us, this is our only option,” says Ms. Boyraz, who also does clerical work at Rutgers University, where she is a Ph.D. student. “And living in New Jersey, there’s so many costs already. Our plan, it’s good for nonemergencies, all the doctors visits I need for my daughter and son, but not for surgeries or anything.”

Her husband, Joseph Boyraz, manages an import-export start-up that sells European furniture, but his small company doesn’t provide employee coverage. Together, they used the federal exchange to purchase a high-deductible plan with AmeriHealth last year, and they pay about $700 of their $1,200 monthly premium, having qualified for a $500-a-month subsidy.

“I wish that health-care reform could be an effort of both parties,” she says, noting the relentless partisan rancor. “But if we lose our plan, I guess we’ll just have to wait for a better insurance plan later.”

Once she earns her Ph.D. next year, Boyraz says she plans to search for a full-time job as an assistant professor. At that point, she says, she would be able to qualify for health insurance through her employer.

The potential impact of a ruling for the plaintiffs, experts say, would not simply be felt by low-income Americans such as Cook and the Boyraz family. Without the subsidies, the insurance industries in these 34 states, as well as the hospitals and health-care providers they pay, would be thrown into a system-wide disarray.

“The bottom line is, there would be chaos,” says Ron Pollack, executive director of Families USA, a not-for-profit health-care advocacy group. “It’s going to create real havoc for insurers, and as a result we’re going to have what people call a ‘death spiral’ in insurance premiums, as fewer and fewer people purchase insurance and the premiums keep on rising.”

This week, a number of Republican senators, anticipating such havoc for the insurance and health-care providers in states who might lose their federal subsidies, called for Congress to offer temporary assistance for those who would in essence be forced off their plans – essentially keeping the Obamacare subsidies in place through the end of his term.

[Editor’s note: In the original version of this story, the Boyraz surname was misspelled.]