(continued from above)
When the ACA was written, it said subsidies were for exchanges "established by the State." That made sense when everyone thought states would cooperate but many didn't. So opponents sued, complaining that people who bought insurance through the federal exchange weren't allowed to get those tax credits. The case, King v. Burwell (2015), went all the way to the Supreme Court.
The Court ruled that Congress meant for subsidies to apply nationwide, whether a state or the federal government ran the exchange. That ruling saved the ACA, but it exposed how fragile it really was. One poorly worded sentence, "established by the State.", nearly destroyed the entire law. Another wrench in the grand plan.
Then came yet another one. The individual mandate penalty for not buying insurance was repealed, thus depriving the grand plan of much needed revenue.
Things haven't worked out the way the architects promised. Yes...some lower income Americans gained coverage, but employer group plans have continued climbing. Self-insured have been squeezed. A huge problem was that cost controls were largely ignored. Furthermore, Congress never allowed cross-state competition, which could have lowered costs by putting pressure on insurance providers. ACA would have never passed if they had.
That brick wall for businesses is still there. Employees covered by employer plans are generally ineligible for subsidized exchange coverage, as are their spouses if the employer's plan meets ACA affordability rules.
Something is still broken in the system. Hospitals, pharmaceuticals, administration, and government regulation continue driving up costs and no one has the backbone to fix them.
Democrats won't touch their signature program, and Republicans still haven't offered a serious, workable alternative.
So here we are, decades later, staring at the same brick wall I saw coming forty years ago.
Then came Trump.
