Potential Implications on Insurance Market if SCOTUS Rules for King
(“Death Spiral”)


KING V. BURWELL -- What Could An Adverse Decision Do to the Cost of Health Insurance? An infographic that vividly illustrates the potential consequences on consumers, insurers and hospitals. 

“Health Insurance is in Jeopardy for Millions of Americans,” Federation of American Hospitals, May 2015

“Health Insurance is in Jeopardy in Florida,” Federation of American Hospitals, May 2015

Frequently Asked Questions 

How Will a Win for King Impact State Insurance Markets? Frequently Asked Questions

Studies and Reports 

Implications of Proposed Changes to the ACA in Response to King v. Burwell, American Academy of Actuaries Issue Brief, May 2015
The issue brief urges policymakers to follow market reform principles for ensuring a sustainable health care system and examines how various policy proposals could play out under a post-King v. Burwell scenario in which federal premium subsidies have been eliminated.

Survey Finds Most in Marketplace Coverage Satisfied with Premiums and Networks, But Affordability Remains Concern, Kaiser Family Foundation, May 2015
Following the Affordable Care Act's second open enrollment period, most people enrolled in marketplace plans report being satisfied with a wide range of their plan's coverage and features, finds a new Kaiser Family Foundation survey of people who buy their own health insurance.

The Implications of a Finding for the Plaintiffs in King v. Burwell for Small Employers, their Workers, and the Self-Employed, Oral Statement of Linda J. Blumberg, Ph.D., The Urban Institute Health Policy Center, Before the U.S. Senate Committee on Small Business and Entrepreneurship, April 29, 2015
Small firm employees, the self-employed, and their family members benefit disproportionately from changes the ACA brought to the nongroup insurance markets. Thus, they would be disproportionately harmed due to destabilization of these markets engendered by elimination of premium tax credits. New legislation to re-instate the ACA’s financial assistance in any state in which it would be prohibited would be required to reverse such damage. 

The Implications of King v. Burwell: Highlights from Three Analyses of the Consequences of Eliminating ACA Tax Credits in 34 States, Linda J. Blumberg, Matthew Buettgens, John Holahan, Urban Institute and Robert Wood Johnson Foundation, March 2, 2015
Update to findings from a January 2015 Urban Institute and Robert Wood Johnson Foundation analysis of the implications of a Supreme Court finding for the King.  

Nearly 7.5 Million Consumers Could Face Premium Increases as a Result of Supreme Court King v. Burwell Ruling, Caroline F. Pearson, Avalere, February 26, 2015
Projects average premium contribution increases by state and estimates the number of people that would gain an exemption from the individual mandate as a result.  Examines the potential impact of a King decision on the employer mandate. 

Health Care Spending by Those Becoming Uninsured if the Supreme Court Finds for the Plaintiff in King v. Burwell Would Fall by at Least 35 Percent, Matthew Buettgens, John Holahan, Linda J. Blumberg, Hannah Recht, Urban Institute and Robert Wood Johnson Foundation, February 12, 2015
Forecasts a 35 percent decrease in health care spending by those that are projected to become uninsured should King prevail.  Breaks out projected impact on hospitals, physicians, prescription drugs, and other spending.

Eliminating Health Insurance Subsidies Will Boost Costs, Cause Millions to Drop Coverage, RAND Corporation, January 8, 2015
Often cited study that models the impact the loss of subsidies would have on insurance markets in affected states, including rising premiums, coverage losses, and a sharp increase in the numbers of uninsured in affected states.

The Implications of a Supreme Court Finding for the Plaintiff in King v. Burwell: 8.2 Million More Uninsured and 35% Higher Premiums, Linda J. Blumberg, Matthew Buettgens, John Holahan , Urban Institute and Robert Wood Johnson Foundation, January  2015
Presents a detailed analysis of the potential implications following a ruling for King, including changes in insurance coverage and premiums.  Frequently cited in other analyses and articles. 

Articles and Blog Posts 

Obamacare case’s threat to small biz workers ain’t small, Dan Mangan, CNBC, April 29, 2015
Discusses testimony before the Senate Committee on Small Business and Entrepreneurship by Urban Institute senior fellow Linda Blumberg where she explains how a King decision would hurt small businesses.

A King v. Burwell ruling for the plaintiffs may not equal death spirals, Joel M. Zinberg, American Enterprise Institute, March 31, 2015
Counter argument to the forecasts of a “death spiral” as a result of a decision that limits the availability of subsidies to state based exchanges.

King v. Burwell and the Mandates: What Happens If the Supreme Court Rules Against the Administration?, Andrew Kloster and Alden Abbott, The Heritage Foundation, March 13, 2015
Discusses the detrimental effect a decision favorable to King would have on the individual and employer mandates and the ACA as a whole.

King v. Burwell Fallout, Lori Robertson, Factcheck, March 11, 2015
Compares and contrasts the findings of several studies, including Urban Institute/Robert Wood Johnson Foundation and RAND studies. 

What if Obamacare Loses?, Robert F. Graboyes, USNews, March 9, 2015
Makes the case that avoiding a “death spiral” would require politically and economically difficult fixes. 

The Day After King v. Burwell: Here’s What Will Happen If 7.5 Million People Lose Health Insurance Subsidies, based on a blog post by Joel Ario, Michael Kolber, and Deborah Bachrach, The Commonwealth Fund, March 4, 2015
Details the detrimental impact that losing subsidies would have on the individual health insurance markets in the affected states. 

Avalere Observations: Impact of King v. Burwell & Potential Fixes, Caroline F. Pearson, Avalere, March 4, 2015
Presents an overview of potential premium increases, loss of enrollees, and regulatory or legislative fixes if King prevails. 

King v. Burwell Explained, Louise Sheiner and Brendan Mochoruk, Brookings Institution, March 3, 2015
Frequently Asked Questions format summarizes the King v. Burwell case and its implications.   Discusses why insurers may choose to leave markets with declining enrollment and deteriorating risk pools. 

Insurance Markets in a Post-King World, Larry Levitt and Gary Claxton, Kaiser Family Foundation, February 25, 2015
Examines how insurers might respond in a market where premiums are insufficient to cover health costs.  Describes a classic insurance “death spiral” scenario.

King v. Burwell: What a Subsidy Shutdown Could Mean for Consumers, Joel Ario, Michael Kolber and Deborah Bachrach, The Commonwealth Fund, February 24, 2015
First in a series of four posts that examine the consequences of terminating subsidies in the 34 states that have federally run health insurance marketplaces.   Post focuses on consumers while subsequent posts highlight issues for insurers, health care providers, and states.

Seven Myths about King v. Burwell, Michael F. Cannon, Cato Institute (also published in Scotusblog.com), November 10, 2014
Argues the plaintiff’s side of the Supreme Court case and downplays the potential impact on insurance markets.

Here’s What the Supreme Court Could Do to Insurance Premiums in Your State, Jonathan Cohn, New Republic, November 11, 2014
Estimates premium increases by state as a result of a King decision and discusses the impact they would have on coverage, including a destabilization of insurance markets. 

Other Resources

Lessons Learned: Washington State’s 1993 Experiment with Health Insurance Reforms, Tom Brown, America’s Health Insurance Plans (AHIP)
AHIP case study detailing the death spiral that ensued immediately after Washington state’s implementation of their 1993 health insurance reform. 

Map: How Many Americans Could Lose Subsidies If the Supreme Court Rules for the Plaintiffs in King vs. Burwell?, Kaiser Family Foundation
Provides state level breakdown of the number of people who could lose premium assistance in 2016.

The Potential Side Effects of Halbig, Larry Levitt and Gary Claxton, Kaiser Family Foundation, July 31, 2014
Discusses the effect on the employer and individual mandates from the Halbig v. Burwell decision, a case similar to King v. Burwell.


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