Post King v. Burwell decision, ministry continues press for coverage expansion

August 1, 2015


When the Supreme Court ruled that low- to moderate-income Americans can keep the tax subsidies that help them afford health insurance regardless of whether they bought insurance on a state or federally established marketplace, advocates for Catholic health care organizations breathed a sigh of relief. Then, they got right back to work on their efforts to expand health insurance coverage for more people.

Community health worker Cindy De La Cruz, left, assists as second grader Domingo Ortiz has his height and weight recorded by a volunteer, nurse Marilyn Hoffman at the Third City Community Clinic in Grand Island, Neb., in July. Nebraska has not expanded its Medicaid program so the school physicals at this free clinic provide many families with needed health care access.

"We need to keep a focus on how important this is," said Marcia Desmond, Catholic Health Initiatives' vice president for public policy, of the ongoing work to insure more Americans and link them to health care. "It's not done." Ministry advocacy executives said they continue efforts to expand Medicaid in states that haven't done so, and through work by their systems to educate more people about how to obtain insurance or access needed health care.

The Supreme Court justices, in a 6-3 decision, ruled on June 25 in the King v. Burwell case. The case focused on whether those who bought health insurance through the federally run insurance marketplaces were allowed tax credits that helped them afford the insurance. A central debate related to language in the Affordable Care Act that referenced subsidies as being for marketplaces "established by the state," thus raising a challenge over whether those who bought insurance through marketplaces run by the federal government could qualify for the insurance subsidies. The court determined they could. Chief Justice John Roberts Jr. wrote for the majority that a fair reading of the legislation allowed for the subsidies. "Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them," he wrote.


The ruling gives more stability to the Affordable Care Act as a whole, said Mike Peters, vice president of government relations–Missouri for Chesterfield, Mo.-based Mercy, preserving insurance for millions even as work goes on to help more gain coverage. About 16 million people in the United States have health insurance due to the Affordable Care Act, the White House recently said, and the Supreme Court ruling allows approximately 8.2 million people to keep their insurance subsidies.

Eye on expansion

Ministry health care advocates around the country said they continue to focus on Medicaid expansion in the 20 states where it hasn't yet happened. That's because when the Affordable Care Act passed in 2010, it required states to provide Medicaid coverage for adults with incomes up to 138 percent of the federal poverty level. However, a Supreme Court ruling in 2012 then determined Medicaid expansion was voluntary for each state. So in states that haven't expanded Medicaid, tens or hundreds of thousands of patients fall into a gap — they do not qualify for Medicaid and earn too little to receive an insurance subsidy that would help pay for coverage through the marketplace. A Kaiser Family Foundation analysis has found that about 9 of 10 people who fall in the coverage gap live in Southern states.

Four days after the King v. Burwell ruling, Ascension's Saint Thomas Midtown Hospital of Nashville, Tenn., served as the site of a news conference involving several politicians and Saint Thomas Health executives. Tennessee hasn't expanded its Medicaid program, but legislators and advocates are working to gather enough support for Insure Tennessee. The program, proposed by Gov. Bill Haslam, was crafted not as an expansion of traditional Medicaid, but as a way to harness the federal Medicaid expansion dollars for two options tailored for Tennesseans.

Insure Tennessee has not yet been approved by the state legislature. If it does pass as currently designed, one of the program's two options would provide participants a voucher to cover out-of-pocket costs in their employer's insurance plan. The other would allow participants to be covered through the state's TennCare program, Tennessee's Medicaid managed care program, but with a cost-sharing component.

Nancy Anness, a family nurse practition-er and Saint Thomas Health's vice president of advocacy, access and community outreach, said many in the state legislature didn't want to vote on a plan until the King v. Burwell decision was made. With the ruling, she's hopeful they'll take up the issue in their next legislative session, which begins in January. She said the proposal crafted in Tennessee could resolve concerns among some residents and lawmakers about Medicaid expansion, while helping those who don't have health care coverage, often due to the cost. "It would be an empowerment program rather than an entitlement program," she said. And as a health care provider herself, she knows how insurance improves patient access to medical homes and routine, preventive care. "I think we'd see healthier outcomes and a healthier state," she said.


Anness encouraged other ministry hospitals and facilities to consider hosting news conferences to raise public awareness of policy options to get more people insured. The news conference in Nashville included politicians across party lines, speaking about ways to help the uninsured. "Catholic ministry can be in the forefront of advocating for 'the least of these,'" she said.

For Englewood, Colo.-based Catholic Health Initiatives, advocacy work will continue to protect the gains already made on health care reform, with leaders keeping an eye on any upcoming efforts to chip away at aspects of the law, including funding or legislative challenges. "We don't want to lose the 16 million we have insured through the ACA," said Desmond. Additionally, five of the 19 states where CHI operates have not expanded Medicaid: Kansas, Nebraska, Tennessee, Texas and Wisconsin, she said. Desmond said from a national level, the system provides as many helpful health reform resources as it can, including information on outreach and enrollment systemwide and talking points about Medicaid expansion, for states where efforts continue.


Outreach and aid
Even as ministry providers continue their push for reform, they are maintaining outreach and aid efforts to support the uninsured and underinsured. Diane Jones, CHI's vice president for healthy communities, said CHI community health workers in many areas continue to educate people about their health insurance options. Also, patient registration staff in hospitals educate patients about insurance and coverage subsidies and assist them in finding a primary care physician. CHI also continues to offer free clinics where patients can receive treatment. Its new HelpCare free clinic recently opened in Kearney, Neb., for poor, uninsured residents of Buffalo and Kearney counties. Nebraska did not expand Medicaid, so such options are a vital way for many people to receive health care.


Copyright © 2015 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.