I used to say Obamacare was a term used by people who don’t like the Affordable Care Act, but I recently heard that the President himself has embraced the term. This week, the nonpartisan Congressional Budget Office released a revised report on the fiscal impact of Obamacare following the U.S. Supreme Court’s decision to allow states the option of not expanding Medicaid. Immediately, politicians said it meant one thing (a massive federal spending program that the country can’t afford) or the other (a coverage strategy that also reduces the deficit). I thought I would do my best to give a couple of dispassionate facts from the report.

The CBO says:

• The Supreme Court ruling allowing states to opt out of Medicaid expansion means that about 3 million fewer Americans will be insured as part of Obamacare. (In its original form, the law was expected to extend coverage to an estimated 33 million people.)
• Another 3 million people who will not be eligible for Medicaid if their states choose not to expand will be eligible for subsidies to purchase their own insurance through the health insurance exchanges slated to open in 2014.
• The federal government’s savings from the average individual who does not enroll in Medicaid is estimated to be $6,000 per person in 2022. But if that individual enrolls in an exchange instead, the federal spending per person will increase to $9,000 on average due to the required federal subsidy.
• Because of the 3 million fewer people being enrolled in Medicaid the law is expected to cost $84 billion less than original estimates over a 10-year period, for a total cost of $1.168 trillion over the decade. The original estimate had been $1.252 trillion.
• Repealing the entire law would increase the federal deficit by $109 billion over 10 years because the repeal would eliminate some new taxes and cuts to Medicare contained in the law. While the government would save $1.171 trillion by repealing the coverage provisions of the law, repealing the entire act would reduce revenues by a total of $1.28 trillion.

I’m an attorney, and I’ve spent virtually my entire career in the realm of healthcare policy. I admit to a bad case of the nerves heading into today. But I am quite thrilled to say the pundits were wrong on this one. Hardly anyone predicted it, but today the Supreme Court of the United States upheld the Affordable Care Act by a 5-4 vote.

The ruling is great news for uninsured Americans and healthcare consumers across the country. While the Affordable Care Act has its supporters and its detractors, there’s widespread agreement that our healthcare system is unsustainable on its current course and changes are needed to reduce healthcare costs and preserve healthcare quality. That work to reform our healthcare system can now continue with the reassurance that the Affordable Care Act will provide the policy foundation to support those efforts moving forward.

Nearly 1 million uninsured New Jerseyans will be added to the insurance rolls over the next two years, thanks to this law. (Although the law will not apply to nearly 400,000 uninsured residents.) Millions more Garden State residents will enjoy protections like access to insurance regardless of pre-existing healthcare conditions and no more lifetime limits on insurance coverage. The law also includes funding, demonstration projects and other innovative efforts to help hospitals, physicians and other healthcare providers reinvent healthcare delivery so it is higher in quality and lower in cost. In short, healthcare reform will help us bring value to healthcare. And that’s important for all of us who count on the reassurance that the care we need will always be there.

We are entering the final countdown for a decision by the U.S. Supreme Court on the constitutionality of the Affordable Care Act (a.k.a “Obamacare” for those who oppose the law.) How do you think the Supreme Court will rule? Will the Court uphold the law, strike it down in its entirety, punt or waver somewhere in the middle?

While there is no consensus on how the Court will rule, most legal scholars agree this is the most watched decision since Bush v. Gore, when the office of the President hung in the balance (along with some hanging chads). Court watchers and the media tell us that the Court is likely to rule toward the end of its session, which concludes June 29. There’s an anxious buzz building – one day last week Twitter exploded with reports that the Court was ready to issue its decision. Turns out it was a false alarm, but it shows the depths of the anticipation.

Lots of people are speculating on how the justices will rule. Some believe the law will be upheld in full, and others believe it will be struck down. There are lots of possibilities in the middle. For instance, the justices could strike down the individual mandate but uphold the rest of the law. Or they could order that a special “master” be appointed to cull through the law to make a recommendation on each individual section. They could punt on a decision until the individual mandate goes into effect and the first person is fined for not having individual coverage (because some have argued the case isn’t ripe for a decision until someone is levied a fine under the law.) The options are limitless, but the consequences are real to the countless uninsured Americans who have the hope of health insurance coverage very nearly in their grasp.

Day 3 of oral arguments on the Affordable Care Act brought more food analogies, as the justices and attorneys debated whether the rest of the law should stand even if the individual mandate is held to be unconstitutional. Most of the attorneys argued, and Justices Scalia and Roberts seemed to agree, that the law is so large, with so many components, that it should fall in its entirety if the individual mandate is declared unconstitutional.

The justices demonstrated a good working knowledge of how Congress operates, noting that some components like the Cornhusker Kickback were added to get votes. Some justices asked whether or not some of the provisions should be allowed to stand because they are clearly constitutional and at least we’d be left with “half a loaf.” But most seem to agree, as I do, that if the mandate is struck down, we will be left with an empty shell and that the component parts of the law were integral to passage of the entire act.

In day 2 of the Supreme Court arguments on healthcare reform, most legal analysts say the individual mandate in the Affordable Care Act is in trouble based on the oral arguments. The good news is that eight justices were very engaged in asking questions (Justice Thomas apparently hasn’t asked a question in over six years). I just heard a snippet of the arguments where Justice Antonin Scalia questioned whether allowing the government to require individuals to buy health insurance could allow them to mandate other purchases. Like broccoli.

It’s a flawed analogy, and here’s why:

• All people need healthcare at some points in their lives, and if they do not obtain insurance, the cost of their care is shifted onto those with insurance. Not the case with broccoli eaters. For them, broccoli is a choice. And if they don’t buy broccoli, they might instead buy peas, beans or vitamins, or nothing at all (in which case they will need our healthcare system!)
• The government doesn’t mandate that all people, broccoli eaters or not, be able to eat free in America’s restaurants when they are really hungry. And they certainly don’t expect other diners to foot the bill for someone who can’t or won’t pay. But that’s what happens in our country with respect to healthcare. Under the federal EMTALA law, all hospitals must treat and stabilize all people who present in the emergency room, regardless of their ability to pay. In New Jersey, the legal mandate goes even further to include not just the ED but all settings.
• There is no supermarket for the uninsured. Hospitals and federally qualified health centers are their safety nets. Commercial insurers aren’t looking to provide them with free insurance. But broccoli is freely available at any grocery store or produce stand.

I’m proud of Justice Scalia and have a deep respect for him. After all, he’s a Jersey boy who made good. But his broccoli analogy leaves me hungry for some thoughtful analysis.