President Barack Obama tried to convince a still sceptical public that his healthcare overhaul has transformed access to care and its affordability, as America’s highest court prepares to rule on a challenge that could throw the system into chaos.
In a major speech, Mr Obama made the case that his sweeping reforms have become embedded in the American social contract over the past five years, dramatically reducing the number of people who do not have health insurance and helping to check spiralling US healthcare costs.
But as the Supreme Court weighs whether to strike down the subsidies that make coverage under the Affordable Care Act attainable for millions of Americans, his signature legislative achievement remains in mortal danger with no concrete plans in place to deal with the political and human fallout.
As the president looks toward cementing his legacy in what he has called the “fourth quarter” of his presidency, there is little on his agenda that could not be considered high stake.
In recent months, he has battled his own party over trade, pushed forward with ambitious climate change goals and edged closer to a final nuclear deal with Iran.
But nothing is as inextricably linked to his presidency as “Obamacare”, and the legal and political battles he has waged over the legislation Republicans are still vowing to repeal and on which the Supreme Court has already weighed in once.
In a case that will be decided by the end of this month, the court is now considering whether people who bought insurance through the federal marketplace, healthcare.gov, should be eligible for the subsidies that are aimed at improving the plans’ affordability.
The law’s challengers argue that a phrase in the legislation, “established by the state”, means that only those consumers who are covered in the 16 states that set up their own insurance exchanges, instead of relying on the federal marketplace, are eligible for the incentives.
A ruling against the Obama administration would mean that 6.4m low and middle-income people in 34 states would be at risk of losing subsidies collectively worth $1.7bn a month, including more than 1.3m people in Florida alone, according to the Kaiser Family Foundation.
Yet neither the president nor Republican leaders have offered much guidance on what steps they would take to deal with the consequences if the court guts such a core element of the law.
Mr Obama has refused to spell out how his administration would help states swamped with residents who may no longer be able to afford insurance.
Currently, consumers making less than four times the federal poverty level — about $97,000 for a family of four — qualify for subsidies under the act, with the average subsidy totalling $272 per month.
Without them, Affordable Care Act enrollees would see their premiums jump by an average of 287 per cent if asked to pay the full cost of coverage, according to the Kaiser study.
In his speech to the Catholic Health Association, Mr Obama reached for the lofty rhetoric he is known for in extolling the law’s aims.
“The rugged individualism that defines America has always been bound by a shared set of values, an enduring sense that we’re in this together, that America is not a place where we simply turn away from the sick, or turn our backs on the tired, the poor, the huddled masses,” Mr Obama said.
“It is a place sustained by the idea I am my brother’s keeper, I am my sister’s keeper.”
But the lack of contingency planning by either party in the event of an adverse ruling from the Supreme Court reflects the disconnect that has developed among American voters: while most still do not like Obamacare, they do not want to see subsidies cut for struggling families.
of people surveyed said they would oppose a decision to block subsidies — even though 54% also said they oppose the Affordable Care Act itself
According to a poll released this week by the Washington Post and ABC News, 55 per cent of those surveyed said they would oppose a decision to block subsidies — even though 54 per cent also said they oppose the Affordable Care Act itself.That has left Republicans in Congress and in governors’ mansions across the country with little room to manoeuvre on how to protect the law’s popular subsidies while effectively dismantling the system they promised to scrap.
Republican leaders have repeatedly said they will not pass a simple language change to the statute without repealing large parts of it, including the so-called “individual mandate” that requires most Americans to have health insurance.
Trying to pass one of several Republican-backed plans to replace the law would be likely to result in a months-long stand-off in Congress, lawmakers have acknowledged.
Many states also lack the resources, budget and political will to build their own exchanges from the ground up, with many of those that are operating facing severe financial challenges.
Mr Obama, for his part, is simply betting that it is a scenario that does not come to pass.
“If somebody does something that doesn’t make any sense, then it’s hard to fix,” the president warned this week. “This would be hard to fix. Fortunately there’s no reason to have to do it, it doesn’t need fixing.”