Democrats and Republicans are sitting on the edge of their seats, waiting to see what the Supreme Court will decide in King v. Burwell, the looming decision about the Affordable Care Act, or Obamacare, as it has come to be known.

If the Supreme Court agrees with the challenge, an estimated 13 million people will lose their federal health insurance subsidies. The plaintiffs have argued that based on the literal reading of the legislation, the government is only supposed to provide citizens with subsidies in states that set up their own health care exchanges (a total of 16 states). The sentence in the law upon which their claim is based, The New York Times reported, was based on a sloppy error made during the drafting process.

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There have been numerous disasters along the way as the federal government and the states have struggled to implement the Patient Protection and Affordable Care Act (a.k.a. Obamacare), but none come close to Oregon’s sorry effort for the millions of dollars lost, the raw political opportunism, and the melodramatic plot twists. Now from the Insult-to-Injury Department comes word that it all could have been avoided.

Earlier this month, five years after President Barack Obama signed ACA, The Hill published a series of articles about how Obamacare is working around the country. It reported that many of the 13 states that established their own stand-alone health-care marketplace exchanges are looking for ways to mitigate the damage and get something up and running before federal funding dries up.

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Sometime in the next few weeks, the U.S. Supreme Court will rule on whether the federal government can subsidize people’s health insurance in the 37 states that haven’t set up Affordable Care Act exchanges. Behind that fight is another one, just as interesting and almost as important: Who gets the blame if the government loses?

The case, King v. Burwell, revolves around a phrase in the law that says insurance subsidies are available on exchanges “established by the state.” The plaintiffs and their supporters say this shows Congress meant to use the subsidies as a cudgel to compel states to create their own exchanges. Now that the strategy has failed, they argue, with some states refusing to build exchanges and instead defaulting to the one run by the federal government, the government should accept the consequences and withdraw those subsidies.

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Senate Republicans want to create a top watchdog to dig into ObamaCare.

GOP Sens. Pat Roberts (Kansas) and Rob Portman (Ohio) have introduced legislation that would create an Office of the Special Inspector General for Monitoring the Affordable Care Act (SIGMA).

The Department of Health and Human Services (HHS) already has an inspector general, but Roberts said he wanted to create a position that could investigate ObamaCare across the federal government.

“While all of the federal agencies charged with implementing Obamacare have their own Offices of the Inspector General, they are all investigating this law in their own silos,” Roberts said in a statement.

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Under Obamacare, doctors have been strained by costly new regulations, intricate payment “reforms” that tie their Medicare reimbursement to complex federal reporting requirements, and mandates that they install and make “meaningful” use of electronic health records.

Add a new burden to the mix: The proportion of patients they see are rapidly shifting away from commercial health plans and toward Medicaid, which sometimes pays doctors pennies on the dollar that they were previously reimbursed under private insurance.

The data comes from ACAview, a product of athenahealth that aims to measure the impact of Obamacare on medical practices. The project, jointly funded with the Robert Wood Johnson Foundation, is the first large-scale examination of data derived directly from outpatient medical practices belonging to more than 60,000 providers. It gives a unique insight into how the Affordable Care Act is impacting patients at the point of care.

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About a decade ago, a doctor friend was lamenting the increasingly frustrating conditions of clinical practice. “How did you know to get out of medicine in 1978?” he asked with a smile.

“I didn’t,” I replied. “I had no idea what was coming. I just felt I’d chosen the wrong vocation.”

I was reminded of this exchange upon receiving my med-school class’s 40th-reunion report and reading some of the entries. In general, my classmates felt fulfilled by family, friends and the considerable achievements of their professional lives. But there was an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.

The complaint was not financial but vocational — an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to “provider.”

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Even as federal regulators take steps to constrain administrative spending by private health insurers, government overhead on health coverage has soared.

In a Health Affairs blogpost published Wednesday, David Himmelstein and Steffie Woolhandler use actuarial estimates from the Centers for Medicare and Medicaid Services to project that between 2014 and 2022, national spending on private insurance overhead and government administration will rise by $273.6 billion related to the health-care overhaul.

The authors both favor single-payer health insurance; Mr. Himmelstein co-founded Physicians for a National Health Program, an advocacy organization directed to that end. They close their piece by saying that “In health care, public insurance gives much more bang for each buck.”

Yet overhead in the public sector is growing much faster than in the private sector.

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New research about implementation of the Affordable Care Act finds that Obama administration regulations are allowing taxpayer subsidized health insurance for some people earning less than the statutory income floor and also for unlawful immigrants.

A new study by Andy S. Grewal, an associate professor at the University of Iowa College of Law, explains that the ACA provides tax credits to U.S. citizens with incomes between 100 and 400% of the Federal Poverty Level (FPL). However, IRS regulations were written to extend credits to citizens below 100% FPL in some cases.

Also, Section 36B of the ACA grants credits to some non-citizens with low-incomes only if they are themselves lawfully present in the U.S. and cannot obtain Medicaid coverage.

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The High Cost Plan Excise Tax, or “Cadillac Tax,” is one of the key provisions of Obamacare, both from the perspective of raising revenue and health policy. Beginning in 2018, there will be a tax of 40 percent on the amount of employer-provided insurance that exceeds a threshold. The threshold is set at $10,200 for individuals and $27,500 for family coverage in 2018, but is adjusted upward each year based on the Consumer Product Index (CPI). The Cadillac tax has been politically contentious from the outset and is garnering increasing attention, in part because some employers are already exceeding the threshold and are contemplating life with the tax.

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45% approve, 52% disapprove of the Health Care Law. The survey of 1,000 Likely Voters was conducted on May 21 and 24, 2015 by Rasmussen Reports. The margin of sampling error is +/- 3 percentage points with a 95% level of confidence. Field work for all Rasmussen Reports surveys is conducted by Pulse Opinion Research, LLC. See methodology.

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