The states that set up their own insurance marketplaces have nothing to lose in King V. Burwell, the big Supreme Court case that will be decided by the end of June. But that doesn’t mean those states are breathing easy.

With varying degrees of difficulty, all of the state-based exchanges are struggling to figure out how to become financially self-sufficient as the spigot of federal start-up money shuts off.

By May 15, insurers had to file 2016 premiums with their state regulatory agencies and provide an explanation for rate increases exceeding 10 percent. On June 1, the Department of Health and Human Services released this information for 41 states plus the District of Columbia. Based on these filings, it appears that premiums for many Obamacare plans, particularly those with large market share, will rise substantially next year. In these states insurers requested double-digit increases for 676 individual and small group plans. These are on top of individual-market premium increases averaging 49 percent between 2013 and 2014.

According to the Centers for Medicare and Medicaid Services, these states include 7.9 million total exchange enrollees – nearly four out of every five people enrolled in exchange plans across the country. The double-digit rate increases HHS reported affect more than six million people in these states. These increases apply for Obamacare plans sold on exchanges as well as Obamacare plans sold off the exchanges. The weighted average premium increase for these six million people is 21 percent. Because the HHS list does not include insurers requesting double-digit rate hikes in large states such as California and New York, final numbers will be even higher.

Obamacare plans have disproportionately attracted older and sicker people. In their rate request filings, insurance companies generally said that claims have been far above what they expected. Moreover, Obamacare contained a large subsidy for insurers through the law’s reinsurance program – equaling $20 billion over three years. The reinsurance program is rapidly phasing out. The combination of these factors means premiums may continue to spiral upward as healthier people choose not to buy the mandate-laden, high-deductible, and expensive coverage.

After a passionate debate, the Florida Senate passed a bill Wednesday that would let a half million people use billions in federal dollars to buy health insurance, and added new measures to address criticism from the House, chiefly that the program would end in three years.

A majority of Republicans supported the controversial health care bill. Earlier this week, a state economist said the plan would save the state money. A top state health official warned it was unclear whether more or less people would gain coverage under the bill.

The unlikely epicenter of Obamacare lies in a solidly Republican working-class town just 10 miles outside the Miami stomping grounds of Jeb Bush and Marco Rubio.
The city of Hialeah — a Cuban-American neighborhood of Spanish speakers that is blanketed with Obamacare advertisements — enrolled more people under the Affordable Care Act than anywhere else in the country.

Monday marked the start of a special session called to pass Florida’s budget. Right on cue, the heavily hospital-connected State Senate is pushing Obamacare’s Medicaid expansion again. With a slightly modified version now rebranded as FHIX 2.0 (or Florida Health Insurance Affordability Exchange Program), the Florida Senate is pushing against a resolute House and a Governor that has all but threatened a veto.

As of the end of the 2015 Affordable Care Act open enrollment period, 11.7 million people had signed up for coverage in a Health Insurance Marketplace (though somewhat fewer likely ended up paying their first month’s premium and getting covered.)

2015 Marketplace signups varied substantially across states when looked at as a share of the “potential market” for the Marketplaces, ranging from a high of 70% in Vermont and 64% in Florida to lows of less than 25% in Iowa, South Dakota, Minnesota, North Dakota, Hawaii, and Alaska.

The Supreme Court is expected to issue a ruling by the end of June in King v. Burwell, a case challenging the legality of health insurance subsidies provided to low- and middle-income people in the 34 states where the federal government is operating the insurance Marketplace under the Affordable Care Act.

With one month until the Supreme Court is expected to rule on King v. Burwell, Pennsylvania submitted a blueprint to the federal government to establish a state healthcare exchange. The plan, submitted on Tuesday, hedges against the possibility that the court could rule healthcare subsidies illegal, a decision that would affect millions of Americans throughout the 34 states that rely on the federal exchange, also known as healthcare.gov.

Officials from states across the nation flew to Chicago in early May for a secret 24-hour meeting to discuss their options if the Supreme Court rules they have to operate their own exchanges in order for residents to get health-insurance subsidies.

A new survey shows that 44% of Covered California policyholders find it difficult paying their monthly premiums for Obamacare coverage.

And a similar percentage of uninsured Californians say the high cost of coverage is the main reason they go without health insurance.

The issue of just how much people can afford will loom large as the state exchange prepares to negotiate with health insurers over next year’s rates.

Many analysts are predicting bigger premium increases for 2016 in California and across the country. Insurers have more details on the medical costs of enrollees, and some federal programs that help protect health plans from unpredictable claims will be winding down.