(Courtesy: U.S. Supreme Court)

Next Monday, the Supreme Court begins considering the Constitutionality of the Affordable Care Act, or ACA. Three days, six hours of oral arguments. But it’s not just one long slog about health care reform. The Supreme Court is considering four different questions over those three days.

Legal scholars, pundits and those suitably opinionated have been pontificating about all kinds of legal issues. But the average American might want to know, in straightforward language, what those Four Questions actually mean.

Here’s my take on them:

1. Can the Supreme Court Consider the ACA Now, Anyway?
Oral arguments Monday, March 26, 7-8:30am PT

This is a question only lawyers can love. Feel free to skip to Question #2 if you like. If you’re still with me, start by going 140 years back in time to the 1867 Tax Anti-Junction Act. No, I’m not making this up–it’s the crux of this first question before the Supreme Court. Here’s the deal: the ACA requires that people purchase health insurance or pay a penalty. Many people say this “penalty” is a tax in disguise. The Tax Anti-Injunction Act bars people from suing over a tax until they actually pay the tax. Since the ACA goes into full effect in 2014, no penalties will be paid until 2015. And so, 2015 would be the soonest someone who paid the tax could challenge the constitutionality of the ACA. Will the Supreme Court punt and say, “Come back in 2015″?  Court-watchers say that’s unlikely. SPECIAL NOTE: If you can only pay attention to two of the three days of hearings, this is your day to skip.

Update: The Supreme Court determined it had the authority to rule.

2. Is the Individual Mandate Constitutional?
Oral arguments Tuesday, March 27, 7-9am PT

Of the four questions the Supreme Court is considering, this is the big one. As you learned in Question #1, the ACA requires all Americans to purchase health insurance or pay a penalty/tax. If your annual income is below a certain level–about $92,000 for a family of four– the government will provide subsidies or tax credits to help you. But the mandate is unpopular. Just over half of Americans think the Supreme Court should declare the mandate unconstitutional, while 28 percent think it should stay. The primary legal question is this: does Congress have the authority under the Commerce Clause of the U.S. Constitution to require Americans to purchase a product, in this case health insurance? Those in favor say yes–Congress can both regulate interstate commerce and legislate taxes. Those opposed say this is the first time Congress has required Americans to purchase a product and it’s unconstitutional. SPECIAL NOTE: if your employer provides health insurance or if you are a Medicare recipient, nothing about your personal situation will change. On January 1, 2014, you would continue to receive the same employer-based coverage or Medicare.

Update: In a 5-4 ruling, the Supreme Court determined that the individual mandate is constitutional.

3. If the Individual Mandate is Unconstitutional, Can the Rest of the ACA Go Forward?
Oral arguments Wednesday, March 28, 7-8:30am PT

Severability. This word will be all over the news next Wednesday. Why? Suppose the Supreme Court decides the individual mandate is unconstitutional. Can the mandate be “severed” from the ACA, allowing the ACA to stand? This question has a bit of unusual background: normally when Congress writes a law, it includes a “severability” clause, so that if one part of a law is struck down, the rest of the law can still stand. Back in the last days of drafting the ACA, the House version indeed had a severability clause. The Senate side expected to add it in a conference committee. But things got so hectic at the end, there was never a conference committee and the severability clause was not part of the final law. SPECIAL NOTE: many experts think severability is implied. They say if the individual mandate is struck down, the rest of the law can stand. Only the Supreme Court will say for sure.

Update: The question of “severability” became irrelevant since the Supreme Court determined that the individual mandate is constitutional. 

4. Is the Medicaid Expansion Constitutional?
Oral arguments Wednesday, March 28, 10-11am PT

Medicaid is the health care plan for the poor and disabled that is run by individual states with both state and federal dollars. The Affordable Care Act expands those eligible for Medicaid to adults earning 133 percent of the federal poverty level. But in order for states to continue receiving any federal money for Medicaid, the ACA requires them to comply with this expansion. Twenty-six states who have challenged this requirement say withholding all monies for Medicaid is coercive and therefore unconstitutional. Those states which support the expansion–including California–say that Congress can constitutionally attach such conditions under what’s known as the “Spending Clause.” SPECIAL NOTE: Congress has expanded Medicaid many times in the past and never had an expansion struck down.

Update: The Supreme Court ruled 5-4 that Congress may not take away all funds for Medicaid if a state decides not to expand the program. As of January 2013, many states have determined to go forward with the expansion; the federal government will pay 100 percent of the costs of any newly eligible enrollees for the first three years and not less than 90 percent of the cost thereafter. Other states have said they will not expand the program; Congress must continue to fund a state’s existing Medicaid program at the existing level.

Some final thoughts:

The Supreme Court’s decisions are expected in late June, possibly early July.
Update: as noted, the decisions came down June 28, 2012.

The Court will make audio recordings available following the end of arguments each day, but turned down requests for live TV or radio broadcasts.
Update: Oral arguments and transcripts on the Medicaid expansion and individual mandate. 

While some elements of the Affordable Care Act have already gone into effect, the major components of the legislation take effect on January 1, 2014.

Learn More:

Background on the Individual Mandate: Court Weighs Making Health Coverage a Fact of Life (AP)

A Guide to the Supreme Court’s Review of the 2010 Health Care Reform Law [PDF]  (Kaiser Family Foundation)

And for you wonks out there, you can find content galore here:
The Supreme Court Decides: Health Care at the High Court (Kaiser Health News)

Jack Snook expresses his appreciation for Healthy San Francisco in a panel discussion last night. (Photo: Kamal Menghrajani)

It’s been almost five years since San Francisco launched its innovative, universal health plan–Healthy San Francisco–and last night a panel of public health experts and care providers gathered at the Tenderloin’s Glide Foundation to provide a snapshot of how the program is faring.

Glide has a long history of providing services to the poor and marginalized–and advocating on their behalf. Glide’s Freedom Hall was packed, with a smattering of people who indicated they were participants in Healthy San Francisco. Tangerine Brigham, director of the program, spoke first and described the program’s goals: to provide improved access to care through a network of community clinics and hospitals. Of primary importance is for people to have a relationship with a doctor or clinic so they don’t resort to the emergency room for what are essentially primary care problems.

Healthy San Francisco is not health insurance. Participants pay a quarterly fee–on a sliding scale–for care at the clinics and hospitals that participate in the program, which are in San Francisco only. But people don’t seem to be bothered by the geographic constraints. A 2009 survey by the Kaiser Family Foundation found that 94 percent of participants were at least “somewhat satisfied” with the program and 92 percent would recommend to a friend.

Karen Hill is the clinic manager at Glide Health Services. As a provider, she is also highly satisfied with Healthy San Francisco. “From a clinic manager’s perspective,” she says, “I don’t have to worry about where I need to send someone for specialty care. I know they have a place to go. … We are going to be able to get those specialty tests they need. We have access for blood tests and for medications.”

As part of San Francisco’s health care overhaul, businesses with more than 20 employees are required to provide health insurance to their employees. Before implementation of the plan, employers–especially restaurant owners–had worried that this requirement would cost jobs, since businesses in surrounding cities and counties might not bear the same health insurance costs. William Dow, Professor of Health Economics at UC Berkeley, has looked at this issue extensively. “Were there fewer jobs in the City after this happened?” he asked, in reference to the implementation of Healthy San Francisco. “The answer is no.” You can read his full analysis here.

The discussion was peppered with comments and questions from the audience. Many spoke in favor of Healthy SF, including Jack Snook. “I think Healthy San Francisco is the best thing that ever happened to me other than being a teacher for 20 years,” he said. “I’m able to easily attain care through Healthy SF. … It’s been a big blessing in my life.”

Looking ahead to the rollout of federal health care reform in 2014, panelists agreed that San Francisco’s near-universal health coverage makes the upcoming change easier. “We will be in a very unique position as a provider community in 2014,” said Tangerine Brigham, “because we will be far better prepared with our residents in Healthy San Francisco to transition either from Medicaid or into another program.”

The panel unfortunately ended before any discussion of cost of the program could be addressed. The San Francisco Public Press–sponsor of last night’s event–featured an in-depth special report last November. The entire edition is worth a read, but one ominous parting note:

The employer contribution raised relatively modest revenues. Of Healthy San Francisco’s total $177 million budget in the last fiscal year, businesses covered just $12.9 million, or about 7 percent. When city officials created the program they envisioned businesses covering $30 million to $40 million, or at least 15 percent of the cost.

The city’s General Fund picked up nearly eight times that amount — $99.7 million. The contributions of individuals opting to buy Healthy San Francisco for themselves contribute just $5.9 million or a bit more than 3 percent of total costs.

Because people who enroll in the pool have been uninsured, there is pent-up demand for health care, experts say. (D. Sharon Pruitt: Flickr)

Thousands of California’s sickest residents are already benefitting from the federal health care law. The Affordable Care Act says that people cannot be denied health insurance for a pre-existing condition. Until the law goes into full effect in 2014, the government has created a bridge program to help–the Pre-Existing Condition Insurance Plan, or PCIP. But this high-risk insurance program is proving to be much more expensive than expected.

California is spending three times more than anticipated to insure the people who have enrolled in this program. Before the program launched in 2010, California projected that the program would cost about $12,000 a year for each member. But a year later the administrators of the program determined it was costing more than $37,000 per patient.

According to a report [PDF] from the White House, the cost of care for PCIP patients across the country is twice as much as originally projected.

As the Washington Post reports:

Those who have enrolled in the program are projected to have significantly higher medical costs than the government initially expected. Each participant is expected to average $28,994 in medical costs in 2012, according to the report, more than double what government-contracted actuaries predicted in November 2010. Then, the analysts expected that the program would cost $13,026 per enrollee.

Looking beyond costs, thousands of people across California are being helped by this plan. Some had been denied coverage because they carry a diagnosis of cancer, heart disease, or kidney failure. Others found that the only insurance they could get was excessively costly, with rates of thousands of dollars per month.

When Gabe Chavez, a 39-year-old father of two from Alameda, was first diagnosed with Type II diabetes, he was only worried about treatment, because he had health insurance.

“All the horrible stories hit your mind. I’m going to die. I’m going to lose a leg.” He knew it would be important to change his lifestyle and felt comforted by his doctor’s support. “You know, it’s treatable,” he told me.

But then Chavez’s company was sold, and the new owners did not provide health insurance. So he went looking for coverage on his own, making innumerable phone calls to insurance providers. “I would say, on a daily basis, I spent two to three hours.”

He went on like this for eight months.

“Everyday, I would call and see if I could get insurance. I even tried to get it from another state. I exhausted every avenue I could find.”

But nobody would provide insurance at a reasonable price. He was paying around $160 to cover his wife and two kids under Blue Cross. To get coverage for himself would have cost an additional $1,200.

Finally, Chavez heard about California’s Pre-Existing Condition Insurance Plan and after going for months without insurance, he was able to get coverage for doctor visits and the medications he needed.

Currently, 6,861 Californians are enrolled in the program. By law, they must have been previously uninsured for 6 months or more. This gap in coverage might be the reason why insuring them is so costly.

“Because they haven’t had health care for a while, they have this pent-up demand,” says Jeanie Esajian, a spokesperson for the state governmental group that runs PCIP here.

“They need medical tests, have surgeries they put off, maybe they have a chronic condition they couldn’t quite get under control,” Esajian told me.

In a sense, Chavez dodged a bullet. He was able to maintain his health during the time he did not have insurance. He now pays $350 a month for coverage, a rate he says he can afford. For him, though, a psychic burden is eased. He had been worried about all kinds of complications–including a diabetic coma. “I just didn’t want to die,” he says. “Health is probably one of the most important things, next to marriage and family. And you want to say healthy for them.”

From Kaiser Health News: In his State of the Union speech, President Barack Obama made just one explicit mention of the 2010 health law. Here is a transcript of the few parts of his speech that mentioned health care issues:

Innovation also demands basic research. Today, the discoveries taking place in our federally-financed labs and universities could lead to new treatments that kill cancer cells but leave healthy ones untouched. …

I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny your coverage, or charge women differently than men. …

Do we want to keep these tax cuts for the wealthiest Americans? Or do we want to keep our investments in everything else – like education and medical research; a strong military and care for our veterans? Because if we’re serious about paying down our debt, we can’t do both. 

The American people know what the right choice is. So do I. As I told the Speaker this summer, I’m prepared to make more reforms that rein in the long term costs of Medicare and Medicaid, and strengthen Social Security, so long as those programs remain a guarantee of security for seniors. …

I recognize that people watching tonight have differing views about taxes and debt; energy and health care. But no matter what party they belong to, I bet most Americans are thinking the same thing right about now: Nothing will get done this year, or next year, or maybe even the year after that, because Washington is broken. …

I’m a Democrat. But I believe what Republican Abraham Lincoln believed: That government should do for people only what they cannot do better by themselves, and no more. That’s … That’s why we’re getting rid of regulations that don’t work. That’s why our health care law relies on a reformed private market, not a government program. …

Above all, our freedom endures because of the men and women in uniform who defend it. As they come home, we must serve them as well as they served us. That includes giving them the care and benefits they have earned – which is why we’ve increased annual VA spending every year I’ve been president.

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Indiana Gov. Mitch Daniels delivered the Republican response. Here are excerpts of his remarks:

[We] must unite to save the safety net. Medicare and Social Security have served us well, and that must continue. But after half and three quarters of a century respectively, it’s not surprising that they need some repairs. We can preserve them unchanged and untouched for those now in or near retirement, but we must fashion a new, affordable safety net so future Americans are protected, too.

Decades ago, for instance, we could afford to send millionaires pension checks and pay medical bills for even the wealthiest among us. Now, we can’t, so the dollars we have should be devoted to those who need them most.

The mortal enemies of Social Security and Medicare are those who, in contempt of the plain arithmetic, continue to mislead Americans that we should change nothing. Listening to them much longer will mean that these proud programs implode, and take the American economy with them. …

It’s not fair and it’s not true for the President to attack Republicans in Congress as obstacles on these questions. They and they alone have passed bills to reduce borrowing, reform entitlements, and encourage new job creation, only to be shot down time and time again by the President and his Democratic Senate allies.

This year, it falls to Republicans to level with our fellow citizens about this reality: if we fail to act to grow the private sector and save the safety net, nothing else will matter much. …

In word and deed, the President and his allies tell us that we just cannot handle ourselves in this complex, perilous world without their benevolent protection. Left to ourselves, we might pick the wrong health insurance, the wrong mortgage, the wrong school for our kids; why, unless they stop us, we might pick the wrong light bulb!

This post has been updated with this additional coverage:

Read More– Kaiser Health News analysis of the President’s limited discussion of health care in the State of the Union address.

(Courtesy: Kaiser Family Foundation)

The video, “La Reforma Del Cuidado De La Salud Llega al Público,” is narrated by Isabel Gómez-Bassols, a psychologist and host of the show “Doctora Isabel, el Angel de la Radio.” While Latinos account for 16 percent of the U.S. population, here in California, they make up 38 percent of the population — and about one-third of them don’t have health insurance.

Check out the video below, or click here.