As Obamacare continues to take effect, and states across the country prepare to launch their health insurance marketplaces by 2014, Americans will soon be able to receive tax subsidies to help them afford their health care plans. That represents one of the health law’s most important initiatives to help ensure that everyone has access to insurance. And, according to a new study from the health care advocacy group Families USA, it’s a provision that will mainly help America’s working poor and middle class.

The Americans whose annual incomes fall between 138 percent and 400 percent of the federal poverty level — which translates to single adults earning less than $46,000 and families of four earning less than $94,000 — will be eligible for Obamacare’s subsidies. Families USA crunched the numbers to find that means about 25.7 million people will soon be able to better afford the high cost of health care. And the vast majority of those people are working Americans, who have tended to struggle to get by in the face of growing income inequality since the Great Recession:

“This reaches deeply into the middle class, as well as moderate-income families,” said Ron Pollack, founding executive director of Families USA, which released the national report. “This is a group that’s really deserving of priority help.” [...]

Most Americans, Pollack said, don’t know how the exchanges will work or that they are eligible for financial help to pay for insurance. That’s why Families USA released the report, he said.

The report shows that families that make between $47,000 and $94,000 will receive half the money, that 88% of the credits will go to working families, and that those up to the age of 36 are most likely to be eligible. Families USA did not include people who fall below 138% of the poverty line because, in the states that will expand Medicaid, they will not need subsidies.

As everyday Americans have struggled to get back on their feet after the economic downturn, the American Recovery and Reinvestment Act — colloquially known as the stimulus — went a long way toward helping lower- and middle-class families regain stability. As Families USA’s new report illustrates, the health care reform law is another federal policy that holds promise for that sector of the population as the country continues to slowly make its way toward recovery.

That’s especially true considering that the cost of health insurance plans has skyrocketed at the same time as American workers’ wages have stagnated. That means low-income Americans are increasingly delaying the health care they need because they can’t afford it. For example, poorer Americans are twice as likely as the people at higher income levels to skip out on their medication to save money. Thanks to Obamacare, many of those Americans will no longer be forced to prioritize their other bills over their health care.

But, as Pollack points out, the majority of the general public still doesn’t realize exactly how the state-level marketplaces will work or how this particular Obamacare provision will directly benefit their families. That fits into the larger national trend about Americans’ persistent misperpections about the benefits of health care reform. Health care advocates point out that there’s still a long way to go when it comes to educating Americans about what the Affordable Care Act actually does for them — thanks, in large part, to the politicized misinformation campaign that has been waged against it over the past three years.

The Los Angeles Times reports that several large health insurers plan to take advantage of an Obamacare loophole that allows them to renew individual policyholders’ current health plans for up to a year without having to conform to Obamacare’s consumer protections and market reforms. That move would lead to uneven implementation of the landmark reform law in its nascent stages, and could drive up prices for other Americans purchasing insurance through the 2014 Obamacare marketplaces.

Insurers offering their customers the option to renew their current coverage could wind up not having to fully comply with Obamacare until well into 2014, depending on the month that the plan was issued. This gives insurers an extension on implementing important reforms to their plans, such as Obamacare’s ban on annual and lifetime benefit caps. While that could be advantageous for certain individual policyholders — mostly the healthier population — reform advocates fear that it will inevitably lead to cherry-picking that shifts costs onto the broader pool of Americans:

Some policy experts are expressing concern about this practice for fear that insurers will focus on renewing younger and healthier policyholders and hold them out of the broader insurance pool next year. Their absence could leave a sicker and older population in new government insurance exchanges, driving up medical costs and premiums there.

“This could undermine the Affordable Care Act, and it opens the door for exacerbating potential rate shock in the exchanges,” said Christine Monahan, a senior analyst at Georgetown University’s Health Policy Institute. “The health insurers can cherry-pick some healthy people and it raises prices for everyone else.” [...]

If an insurer offers this option, it would then be up to consumers to decide whether they want to renew an existing policy into 2014. The length of any renewal may depend on what month their annual plan year begins. [...]

Renewing an older policy could mean forgoing some of those richer benefits and new limits on out-of-pocket medical expenses.

So far, large insurers are split on whether or not they will take advantage of this loophole. UnitedHealth Group hedged on their intentions to the Times; WellPoint — which runs Blue Cross plans in many states — said that its approach would differ from state-to-state; Kaiser Permanente was the only large provider to explicitly state that it would not renew existing plans beyond January 1, 2014.

Insurers choosing to take advantage of the loophole are simply delaying the inevitable, and will cause significant damage to sicker or poorer Americans without individual policies in the process. That’s why certain states, including California and Oregon, are considering taking legislative action to prevent or substantially limit such dodges by health insurers. As Oregon Insurance Commissioner Louis Savage — whose office issued a rule in the state barring any extension beyond March 31, 2014 — told the Times, “We want to get as many people as possible into the exchange. I think having renewals go deep into 2014 is counterproductive to the goals of the federal healthcare law.”

From the minute that President Obama signed his landmark health reform bill into law, conservative critics have been issuing dire warnings about how expensive Obamacare will make employer-sponsored health coverage, asserting it would be cheaper for larger companies to drop coverage for their workers — and pay a fine if their employees obtain federally subsidized coverage through Obamacare’s insurance exchanges — rather than provide basic health benefits. As it turns out, those predictions aren’t actually becoming reality.

According to Modern Healthcare, a new “survey of nearly 800 large and midsize employers found that just 6 percent of respondents intend to completely exit the healthcare system over the next three to five years” over concerns about the penalty that Obamacare will level against large companies that don’t provide adequate benefits for their workers.

That assessment stands in stark contrast to some Obamacare opponents’ more outlandish claims. Major conservative institutions and healthy policy experts — including the Heritage Foundation and Douglas Holtz-Eakin, who is a former Congressional Budget Office (CBO) director — have predicted that anywhere between 20 million and 35 million Americans will lose employer-sponsored insurance because of Obamacare. Even respected consulting firm McKinsey and Co. predicted that “30 percent of employers will definitely or probably stop offering [employer-sponsored insurance] in the years after 2014,” the year that most Obamacare provisions — including the employer mandate — kick in.

In fact, that kind of mass exodus would be fraught with risks for companies, considering that approximately 70 percent of Americans receive health coverage through their employer. The prospect of losing workers over decreased benefits is a powerful disincentive for the companies that might have considered ditching health coverage to cut costs. As Jim Winkler of Aon Hewitt’s U.S. health and benefits department put it, employers’ incentive to stop sponsoring health insurance “is strong until you look at the numbers. Between the [Patient Protection and Affordable Care Act] penalties for failing to offer coverage and the ensuing talent flight risk, most employers believe they need to continue to play a role in employee health.”

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This past Friday was the final deadline for governors to decide whether they will take some ownership over setting up a state-level health insurance exchange, as stipulated by the Affordable Care Act. But even though the Republican Party typically resists handing over any power to the federal government, the vast majority of GOP governors have decided to cede control over their own insurance marketplaces to federal officials — an uncharacteristic move that’s out of step with GOP ideals.

As stubborn Obamacare opponents continue to resist implementing the health care reform law, most governors have refused to do any work to set up an insurance marketplace. But those GOP-led states’ refusal won’t actually bring health reform to a grinding halt; instead, it has invited the federal government to step in and do the work for them. Altogether, the federal government will run health exchanges in 26 states, and partner with state officials in an additional seven states to help them set up their marketplaces:

Even though you wouldn’t know it from looking at the partisan breakdown in the chart above, state-run health exchanges are actually a conservative idea. Democratic proponents of reform initially advocated for a nationally-run insurance marketplace, but the final version of the health reform law gave more control to states in order to compromise with conservatives. Republican governors are now largely refusing to take advantage of the power that the law affords to them.

Ironically, as Wonkblog’s Sarah Kliff points out, GOP leaders’ refusal to set up their own exchanges means they’re defaulting to a more liberal version of health care reform. Some members of the Republican Party have already recognized this — but their attempts to convince their colleagues to implement Obamacare on a state level haven’t been met with much success, since the facts don’t matter to the partisan lawmakers who will stop at nothing to oppose the health reform law.

Wisconsin Gov. Scott Walker (R) has decided to reject Obamacare’s optional Medicaid expansion, opting instead for an alternative — and risky — plan for providing low-income Americans with private health coverage that will prevent many of them from accessing the types of services that they can get under Medicaid.

As Politico reports, Walker’s plan “would take thousands of people currently on Wisconsin’s relatively generous Medicaid program — people who are above the federal poverty level — and move them into the Obamacare exchange instead, where they can get federally subsidized private insurance.” The plan would actually cut Wisconsin’s Medicaid program in the aggregate, shifting low-income Wisconsinites above the federal poverty level away from the public insurance program and into the state’s Obamacare-funded private insurance marketplace. It is also estimated to cut the state’s uninsurance rate in half, and Walker claims that the move is intended to “preserve an essential safety net for our neediest, while protecting our state’s taxpayers from uncertainty” over whether or not the federal government will follow through on its promise to fund the lion’s share of states’ Medicaid expansions.

While it’s an interesting proposal from a GOP governor who is not known for compromising with political opponents, it’s still a raw deal for low-income Americans, as it will restrict the number of specialty medical services that poor Wisconsinites have access to. That’s because Medicaid provides a range of benefits that lower-tier private health plans — which are the only kind that poor Americans will be able to afford under Walker’s plan — don’t cover. As Harold Pollack wrote for The Incidental Economist, “There is no genuine private-sector equivalent for many Medicaid services provided to disabled individuals with special needs.” Those services include specialized benefits such as home care and social worker visits to assist impoverished first-time moms — benefits that might not be necessary for well-positioned Americans who may opt for a lower-cost health plan, but make an enormous difference to low-income populations with unique needs.

Physical disabilities, mental health issues, and a whole host of other socially and financially costly medical conditions disproportionately plague low-income Americans. To illustrate exactly how Walker’s alternative to expanding Medicaid will tangibly affect Wisconsin residents, consider a low-income pregnant woman who suffers from depression. Medicaid currently covers mental health services for “medically needy” pregnant women up until six months after they give birth — but states that expand Medicaid under Obamacare will be able to provide moms these mental services for long after that cutoff. Granted, private plans sold on Obamacare marketplaces must meet federal benchmarks and provide an array of “essential health benefits,” including mental services. But the rules governing the scope and quality of these services are much less stringent for private plans than they are for Medicaid. That’s pretty significant considering the fact that 82 percent of infants living in households with depressed mothers were enrolled in Medicaid or CHIP programs.

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After surviving a Supreme Court challenge, dozens of repeal attempts in Congress, and a presidential election, Obamacare is here to stay — and even some of the staunchest opponents of the health care reform law are finally starting to take steps to implement its provisions in their states. But that doesn’t mean anti-Obamacare Republicans aren’t still dreaming up new ways to create roadblocks to health care reform. In the battle to implement the health law on a state level, GOP officials have seized on an opportunity to hide behind Obamacare to limit women’s access to abortion services.

This week, Arkansas became the latest state to ban Obamacare’s state-level health insurance markets from offering any type of abortion coverage. Michigan and New Jersey are currently considering the same type of legislation. Eighteen other states already have similar bans in place, and two more — Kentucky and North Dakota — have laws on the books to mandate the exact same restriction on abortion coverage, even though they don’t mention the health reform law itself.

All told, the American Civil Liberties Union has mapped out 20 states where at least some women who are seeking to terminate a pregnancy can’t get insurance coverage for that legal medical procedure — including eight states where women can’t get any coverage whatsoever for abortion care:

Abortion services are simply another aspect of women’s reproductive health care — along with other potentially expensive services such as HPV vaccinations, regular gynecological exams, family planning services, and maternity care. Because of the range of gender-specific health services that women rely on, they already tend to pay significantly more for their basic health care than men do. Obamacare takes big steps to address the gender-based disparities in health insurance costs, partly by eliminating co-pays for many of women’s essential preventative services, like contraception.

But since the health reform law leaves abortion services up to each state to determine, anti-choice lawmakers are twisting Obamacare’s provisions to punish the women who seek abortions by forcing them to pay huge out-of-pocket costs in order to make their own medical decisions. “Abortion coverage restrictions were a nonissue for an incredibly long amount of time,” Elizabeth Nash of the Guttmacher Institute explained to Politico. “That law really encouraged states to go in and pass these abortion coverage restrictions in their own health exchanges.”

And now, women’s health advocates worry that — even though Obamacare itself doesn’t prohibit abortion coverage in its insurance marketplaces — anti-choice activists are successfully construing the health law so it appears to be a vehicle for restricting women’s reproductive rights. Fortunately, that’s not the case in every state. Connecticut lawmakers have taken the opposite approach to the issue and opted to classify elective abortion services as an “essential health benefit” under Obamacare, ensuring that insurers will have to cover the procedure.

Over the past several years, it’s seemed like Republicans would never give up the fight against Obamacare. Even after the health care reform law survived a Supreme Court challenge, dozens of repeal efforts in Congress, and a presidential election, GOP governors across the country stubbornly resisted moving toward implementing health care reform — even at the expense of their state’s low-income residents. But that tide may finally be turning.

As Politico reports, some Republican governors are starting to resist the pull of the rest of their party and move ahead with key parts of President Obama’s health law. Five Republicans governors have now agreed to Obamacare’s optional Medicaid expansion, and three GOP leaders are pursuing state-run insurance markets. The growing number of Republicans who are beginning to cooperate with health care reform, as well as the fact that repeal efforts aren’t gaining much traction in Obama’s second term, may signal that the partisan fight over Obamacare is finally past its prime:

These state moves represent a turning point in the fight over Obamacare. Outside the Beltway, GOP governors are living with the reality that there’s nothing they can do to stop the law, so some are trying to carry it out on their own terms. And Republicans back home and in Washington aren’t giving their governors hell for giving in to the ACA — even if The Wall Street Journal editorial page doesn’t like it. [...]

Dan Derksen, who used to oversee Affordable Care Act implementation in New Mexico and is consulting on Arizona Gov. Jan Brewer’s Medicaid expansion plan, called the governors’ decision to implement major pieces of Obamacare “courageous,” given the partisan opposition to the law.

“I just think that when you look at the data and what it means to the constituency they represent, they’re making a data-driven, evidence-based, informed decision,” said Derksen, a Republican. “I admire the courage of governors like Sandoval, Martinez and Brewer.”

With the exception of New Mexico, all the GOP-led states that have indicated support for implementing Obamacare were part of a lawsuit against the health law challenging the constitutionality of its individual mandate. But the political reality is different now, particularly since public support for Obamacare is growing now that Americans are beginning to experience the positive effects of some of its new provisions.

However, that doesn’t mean every Republican leader in the country is on board. Ten GOP governors have already rejected Obamacare’s Medicaid expansion, even though some of their states have the highest rates of uninsurance in the nation. And some Obamacare opponents are keeping the fight alive on a state level, proposing legislation to block state officials from implementing health reform.

By January of next year, Obamacare will require Americans to have insurance coverage, either through their employer or through one of the health law’s statewide insurance marketplaces. In order to make that coverage affordable, the law provides progressive insurance subsidies in the form of tax credits for Americans buying coverage on the marketplaces and fines companies that don’t cover their workers. But an existing loophole in the law may leave some American families in a coverage gap — and Congress may not be able to agree on a solution to fix the glitch.

The families in question would be unable to afford family health plan premiums through their employer, while also ineligible to qualify for the subsidies to help them buy an alternative plan on an Obamacare exchange. As Modern Healthcare explains, the loophole has to do with the definition of what is considered “affordable” coverage under the law, which is directly related to the federal subsidies that a family is eligible to receive:

Congress said affordable coverage can’t cost more than 9.5 percent of family income. People with coverage the law considers affordable cannot get subsidies to go into the new insurance markets. The purpose of that restriction was to prevent a stampede away from employer coverage.

Congress went on to say that what counts as affordable is keyed to the cost of self-only coverage offered to an individual worker, not his or her family. A typical workplace plan costs about $5,600 for an individual worker. But the cost of family coverage is nearly three times higher, about $15,700, according to the Kaiser Family Foundation.

So if the employer isn’t willing to chip in for family premiums — as most big companies already do — some families will be out of luck. They may not be able to afford the full premium on their own, and they’d be locked out of the subsidies in the health care overhaul law.

Ron Pollack, the executive director of the health care advocacy group Families USA, told Modern Healthcare, “This is a very significant problem, and we have urged that it be fixed. It is clear that the only way this can be fixed is through legislation and not the regulatory process.”

Unfortunately, that doesn’t bode well for the American families who fall inside of this coverage gap. While Obama Administration officials have called for a fix, the GOP-controlled House of Representatives has been staunch in its refusal to do anything with Obamacare other than obstruct its funding sources. Some Republicans have gone even further than that, attempting to strip away the law’s federal insurance subsidies to Americans in states that choose not to implement their own exchanges, claiming that a semantic technicality in Obamacare forbids assisting Americans in such states from buying coverage — a move that the Administration has vehemently rejected, since it would financially devastate Americans in half of the country.

The IRS has instituted certain regulations in an attempt to mollify the impact of the loophole on American families, ruling that families that fall into that coverage hole will not be subject to the law’s penalty for not purchasing insurance. All in all, very few Americans will actually be subject to the individual insurance mandate penalty, and 80 percent of those who will have incomes higher than the federal poverty level. Still, that may end up being small comfort for the Americans whose employers choose not to pitch in for family health plans.

A state senator in Idaho is expressing her distaste for President Obama’s health care reform law by drawing a comparison between the private insurance companies participating in Obamacare and the “Jews boarding the trains to concentration camps” during the Holocaust.

According to Sen. Sheryl Nuxoll (R), Idaho should refuse to set up a state-run health exchange under Obamacare because, although the federal government is using private insurers for the time being, the Obama administration will eventually “pull the trigger” on those companies to establish a socialistic health care system.

Nuxoll posted her comments on Twitter, as well as included them in an email blast to 120 supporters:

The insurance companies are creating their own tombs. Much like the Jews boarding the trains to concentration camps, private insurers are used by the feds to put the system in place because the federal government has no way to set up the exchange. Based on legislation and the general process that is written toward this legislation, the federal government will want nothing to do with private insurance companies. The feds will have a national system of health insurance and they will eliminate the insurance companies.

When the Idaho Spokesman-Review asked Nuxoll to clarify her comments, she doubled down on them. Nuxoll said she didn’t mean to disrespect any group of people with her analogy, and explained she said it because “I felt badly for the Jews — it wasn’t just Jews, but Jews, and Christians, and Catholics, and priests. My thing was they didn’t know what was going on. The insurance companies are not realizing what’s going to end up in their demise.”

Idaho’s Senate President Pro-Tem, Brent Hill (R), also stood behind Nuxoll. “This is a very emotional issue for a lot of people,” Hill told the Spokesman-Review. “There’s a lot of ‘stuff’ going around, a lot of information, a lot of viewpoints being expressed. As we get closer to making that decision, the rhetoric’s going to get more dramatic.”

While Idaho Gov. Butch Otter (R) is a vocal critic of health care reform, he has agreed to set up a state-run exchange under Obamacare because he has acknowledged it will allow Idaho to retain more control over its own insurance market. The federal government will simply step in and set up exchanges in the states that refuse to do so themselves. Obamacare’s health exchanges, along with the health law’s optional Medicaid expansion, seek to extend health care to an estimated 30 million low-income Americans who are currently uninsured.

The verdict is in: Americans don’t just support Obamacare — they consider implementing its central tenets a “top priority” for their state legislatures.

A new Kaiser Family Foundation/Robert Wood Johnson Foundation/Harvard School of Public Health poll finds that strong majorities of Americans consider implementing Obamacare’s statewide insurance exchanges and Medicaid expansion either a “top” or “important” priority for their state:

Americans increasingly embrace Obamacare as it is implemented. Although public sentiment on the landmark reform law was ambivalent as it was being debated in Congress, Americans have consistently supported its individual provisions, and support for fully repealing the law plunged to an all-time low after the presidential election. And House Republicans can’t find any co-sponsors for their latest Obamacare repeal bills now that the president is beginning his second term.

But GOP governors don’t seem to have gotten the memo. Only four Republican governors have expressed support for expanding their states’ Medicaid programs, while the vast majority — including those representing some of America’s poorest and least-insured states — have refused to participate in the expansion, despite the fact that expanding Medicaid will actually save states billions of dollars. The outlook for the Obamacare insurance exchanges is also grim, with as many as half of U.S. states refusing to set up their own exchanges, deferring instead to the federal government.