Numbers are so, weird. They lack emotion, judgement, subjectivity. And yet they are reflections of ourselves. And we are so willing to manipulate them, fight over them, use them to control one another. They are the good and the bad in us. I know you know this.
But this week, I was reminded of this yet again, when I tried to count states and draw a map.
It was a really tough week. On Wednesday, the Supreme Court heard oral arguments on the King v. Burwell case. That’s a case that will decide whether the feds get to continue giving the subsidies that help people pay for healthcare in a whole bunch of states (Did you get the “a whole bunch” bit? Hold on to that). You can read about the case on Vox in a really good explainer here. Even Michael Cannon likes it (and he doesn’t like the ACA much), except for these parts.
Numbers really matter in this case, and I want to talk about them, but perhaps not in the way that you think. You might be thinking that I’m about to make the case that the people in the states at risk won’t be able to pay for health insurance if they lose subsidies, and that I’m about to show you those numbers, but I’m not. That’s my day job.
How many states would lose subsidies if the Supreme Court decides in favor of the plaintiffs in King v. Burwell?
I want to talk to you about numbers in a different way. Here they are:
- “more than 30”
The numbers above illustrate some of the ways in which different sources (news outlets, pundits, policy experts, advocates, my mom… okay, not my mom… but I bet she’d have an opinion if I asked her) are reporting the number of states that could or would (yes, that distinction is important) lose subsidies if the Supreme Court decides to take them away.
I was trying to design an infographic to illustrate how many states were at risk of losing these subsidies. I figured on about 45 minutes to create a map and a bar chart. But I couldn’t. Because there wasn’t a number. Or rather, because there were many. And each number was more loaded than the rest.
How many states would lose subsidies if the Supreme Court decides in favor of the plaintiffs in King v. Burwell? It’s like the beginning of a “How many people does it take to screw in a lightbulb…” joke. Except there’s no punchline because it’s not funny—families get to lose their health insurance over this one.
So my straightforward question took me down a long, sad rabbit hole of politics, healthcare, and the Supreme Court.
Seriously, how do you count states?
To understand why these numbers matter, you need a basic understanding of how the healthcare exchanges are structured. Bear with me for four sentences. Under the ACA, each state plus the District gets to choose whether to set up its own health insurance exchange or to let the feds do it:
- If the state sets up its own exchange, it’s called a state-based marketplace and there are 14 (including DC)
- If the state lets the government do it, it’s called a federally facilitated marketplace and there are 27
If the above two categories were it we’d be all squared away, just a knock-down-drag out fight over people trying to take healthcare away from low- to- middle-income people. No numbers involved. But there’s a gray area with states that have partnerships—and not everyone agrees which of the above categories these gray states could fall into if the ruling goes down.
- Some state exchanges are called partnerships (a state-partnership marketplace and there are 7 to be painfully precise). This is where the states and the feds divvy up the work of administering the exchange and the whole thing is run off the federal website—healthcare.gov
- There are also states that do all the heavy lifting of administration and just use healthcare.gov as a technology platform. They basically have a state-based marketplace but happen to run it off the fed website—Oregon, Nevada, New Mexico. (If you are a glutton for wonk terms this is called a federally supported state-based marketplace and there are 3 of these states).
Kaiser has a nice wonky chart that lays it all out here.
Why is the number of states so important in King v. Burwell
Now, the lawsuit in King is basically an argument over which states with which types of exchanges get to give subsidies. The plaintiffs claim that the law intended for subsidies to be provided only to states that run their own exchanges (state-based marketplaces). That requires a definition: What, exactly, is a state that runs its own exchange? And a number: How many states do that?
Then there are those three “gray area” states in play (Oregon, Nevada, New Mexico) that make counting things more complicated: Do they/don’t they meet criteria for being state-based marketplaces? Depending on who you ask, they’re either at risk (see above) or doing just fine, thank-you-very-much (see above). (I know people that would run me out of town for even asking that question. To those people I say, “Yes. They are state-based marketplaces. But not everybody agrees with you. See above.”)
If you are interested in more of an explanation of the politics behind the three “gray area,” so was I and so was Charles Gaba, who is waaaaay smarter than me. His popular ACA blog sums up a longer Politico piece here. The title is as good as the answer: In which Politico reporters Racahan Pradhan & Brett Norman FINALLY answer a question I’ve been wondering for months… (and here’s the original Politico article).
And this matters, why?
Because depending on how the lawsuit goes, which state counts as a state-run marketplace affects who gets subsidies and who doesn’t, either through how the court defines it or how the rules define it after a decision gets handed down. I don’t have the brainpower or the will to begin to cover the arguments in this blog, so I won’t attempt to do so. But it matters. Just ask the people who won’t be able to afford health insurance once they lose their subsidies.
So we have a situation where prominent sources are reporting the numbers differently, and it’s confusing, and it’s political.
These numbers are being reported very differently by, um, everyone. Not just proponents and opponents of the law. Everyone.
- Some count 13 states plus DC as having exchanges with “state-based marketplaces”, which means that they report 37 states at risk of losing subsidies.
- Others count the 13 states plus DC and also what I call the three other “gray area” states (Oregon, Nevada, New Mexico).
- Others use more nebulous characterizations (see below).
Here’s a sampling of the most common reporting that you’ve likely seen already:
- 37: Kaiser shows a straightforward 37 states being “at risk” and 14 (including DC) being “secure”
- 34: New York Times reports 34 states for sure with three unclear (Oregon, Nevada, New Mexico). Accordingly, the map highlights 37 states at risk with just 13 “safe” states plus DC, describing these 14 as “states that have their own exchanges and would not be affected by any ruling”
- 34: The Urban Institute
- 34: A recent RAND study defines states with federally run exchanges (federally facilitated marketplaces) as 34
- 34: In explainer cards, Vox describes the lawsuit as specifically contesting subsidies in 34 states. In other articles, it goes into more details.
- Two thirds, three dozen: Harvard’s Center for Health Law and Policy Innovation and my own employer, Families USA, (both of whom filed amicus briefs in the case) use two thirds and three dozen, respectively.
- More than 30: This New York Times article characterizes those that “would” lose subsidies (different than those who “could”) as “more than 30”
So why can’t a poor designer simply catch a break and just draw a map?
Well, politics, obviously. That’s part of the point of this post. To shed light on just how murky things get for the people whose job it is to make things…er… clear.
If you’ve got a day job, drawing a map can mean visualizing—not data—but the political stance of your organization.
You’re caught in the cross-fire between your craft—show what you see/know—and the advocacy goals of your organization. Or, for that matter, the politics of the issue itself independent of your organization. Things don’t always align neatly.
Oh, by the way, I did draw the map for this blog post. Please enjoy it.
It’s complicated. But there’s another catch.
And can I just say one more thing? This is a shameless plug for my own outfit. If you really are interested in what will happen to the people who will lose their subsidies (I’m totally serious), please watch this video. Regardless of what “number” we ultimately settle on, not much good will come of it if these families lose their subsidies and can’t afford to pay for health insurance. You can hear them tell you about it in their own words. It’s pretty compelling and yes, we produced it.