Policy wonks and health industry leaders have eagle eyes on the U.S. Supreme Court this week. And so does Darlene Ables.
The 57-year-old self-employed home health care worker knows what is at stake in the arguments that began before the Supreme Court on Wednesday: Her health insurance.
Ables, of Soddy-Daisy, had gone without coverage despite health problems for years, and she is able to afford the pricey insurance plan she bought through HealthCare.gov last year only through the tax subsidies that are a part of the exchange.
Without the subsidies, Ables' premium is $415 a month. With them, it's $23, confirmed American Exchange, the broker that signed Ables up for the plan.
Like Ables, the vast majority of the hundreds of thousands of tri-state residents who bought insurance plans on HealthCare.gov this year were helped by tax credits. In Tennessee the average subsidy per person per month was $211.
The legality of those subsidies is at the heart of the case before the Supreme Court, called King v. Burwell. The question hinges on whether the tax credits can be used in federally run exchanges, or just in those that are state-run.
By the numbers
Tennessee 229,093 - Number of Tennesseans who signed up for insurance through HealthCare.gov 82 percent - Percentage of those who qualified for tax credits, as of Jan. 31 $211 - Average monthly tax credit per person to put toward premiums Georgia 536,929 - Number of Georgians who signed up for insurance through HealthCare.gov 90 percent - Percentage of those who qualified for tax credits, as of Jan. 31 $277 - Average monthly tax credit per person to put toward premiums Alabama 168,816 - Number of Alabamans who signed up for insurance through HealthCare.gov 89 percent - Percentage of those who qualified for tax credits, as of Jan. 31 $268 - Average monthly tax credit per person to put toward premiums Source: U.S. Department of Health and Human Services
If the court limits subsidies to states that run their own exchanges, the tax credits will no longer be applicable in 37 states that rely on HealthCare.gov -- including Tennessee, Georgia and Alabama.
"I could not afford this plan without [the tax credits]," said Ables, who said that she copes with a number of health problems. "I'm just watching this and I'm thinking -- if they cut this out, what will I do?"
Nancy Ridge, who leads health insurance navigator efforts at the Chattanooga Medical Foundation, said she worries for the people her staff signed up this year.
"I know a great percentage of them will not be able to afford the insurance without those subsidies," she said.
Tennessee's largest insurer, BlueCross BlueShield of Tennessee, did not respond to questions about contingency plans if the court denies subsidies for federally run exchanges this summer.
"We can't speculate on the King v. Burwell decision," BlueCross spokesman Roy Vaughn, said in a statement. "However, we feel it is critically important that as many Tennesseans as possible get and stay covered."
Millions of people could be affected by the court's decision, The Associated Press reported.
The Obama administration says it would make no sense to condition subsidies on where people live, and that doing so would set off a "death spiral" in which enrollment declined, driving premiums up and leaving only the sickest, and costliest, people insured.
On Wednesday, liberal Supreme Court justices peppered opponents of President Barack Obama's health care law with skeptical questions during oral arguments, the AP reported.
The outcome in what Justice Elena Kagan called "this never-ending saga" of Republican-led efforts to kill the Affordable Care Act appears to hinge on the votes of Chief Justice John Roberts, whose vote saved the law three years ago, and Justice Anthony Kennedy.
Roberts said almost nothing in Wednesday's 85 minutes of lively back-and-forth, and Kennedy, who voted to strike down the health law in 2012, asked questions of both sides that made it hard to tell where he might come out this time.
Otherwise, the same liberal-conservative divide that characterized the earlier case was evident in the packed courtroom with the same lawyers facing off as in 2012.
Justice Ruth Bader Ginsburg said the law set up flexibility for states to either set up their own markets or rely on federal healthcare.gov. Giving subsidies only to people in some states would be "disastrous," she said. "I have never seen anything like this," Ginsburg said.
When Solicitor General Donald Verrilli Jr. stepped to the lectern, the liberal justices fell silent, and Justices Samuel Alito and Antonin Scalia took over. They questioned Verrilli over the words "established by the state" that the challengers say are clear and conclusive evidence that Congress wanted to limit the subsidies to state-run exchanges.
"I mean, it may not be the statute they intended. The question is whether it's the statute that they wrote," Scalia said of the provision in question.
Verrilli argued the law can be read only broadly because its very purpose was to reduce the ranks of the uninsured.
A decision is expected by late June, the AP reported.
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In the meantime, Ridge is trying to assure her clients they can still use their insurance, and that they still need to pay their premiums.
While there is little role for grassroots advocacy in the case, Tennessee health advocates say there is plenty of fight at home over the issue.
Sen. Brian Kelsey, R-Germantown, has proposed a bill that would block Tennessee from creating its own state-based exchange. Kelsey has said he hopes the Supreme Court will rule against the federal government, which will "lead to meaningful, conservative health care reform."
Kelsey was one of seven senators to vote down Gov. Bill Haslam's Insure Tennessee proposal. One of the leading conservative groups to oppose that plan, the Beacon Center, also expressed hope that King v. Burwell will signal the end of so-called Obamacare.
"The fact that millions could have their perceived safety nets ripped from underneath them would be a tragedy -- not because the subsidies to non-exchange states were overturned (because they are illegal and should be, since the Supreme Court's responsibility is to uphold the rule of law), but because the president promised affordable health care, and delivered higher taxes, higher deductibles, robust mandates, and broken promises," Beacon Center director of policy Lindsay Boyd wrote in the group's blog.
Michele Johnson, executive director of the Nashville-based legal advocacy group Tennessee Justice Center, characterized Kelsey's bill as his attempt to "score political points."
"For the first time, many of these people who were previously uninsured have peace of mind and financial stability," she said. "It's also important for all the rest of us that they stay covered, because if not, they add to the burden of uncompensated care in the state."
As arguments continue, Ables said she is just trying to use her newfound coverage to stay healthy.
"It has made sure I can get back and forth to the doctor," she said. "If I'd had a doctor earlier, I may not have been in the condition I am today."
Contact staff writer Kate Belz at kbelz@timesfreepress.com or 423-757-6673.