This morning, the Supreme Court handed down a ruling on an important element of the Patient Protection and Affordable Care Act (ACA). The ACA was signed into law in March 2010. The issue was whether citizens who purchased healthcare insurance through the federal healthcare.gov website are entitled to a subsidy if they qualify. The legislation specified the subsidy was only for those who used a state-run health insurance exchange. Only 17 states built an exchange. The others chose to use the federal exchange. The ruling upheld ACA subsidies for all Americans regardless of what exchange they used. Some pundits are calling this a major political gain or loss. I do not see it that way. The issue was not about whether the ACA is good or bad. The issue was a very specific and narrow one. Six of the nine justices believed the intent of the legislation was to provide subsidies to those who qualified and obtained insurance through a health insurance exchange. The ruling protected the subsidy for 6+ million people. The bad news is that 30+ million people remain uninsured. As I wrote in Health Attitude, 40-50 thousand people per year die because they have no insurance. Just because they have no insurance. The ERs never turn a patient away, but the hospital will not admit a patient with no insurance. A person presenting his or her self to the ER with excruciating abdominal pain will be seen by a doctor and may receive a CT scan to help diagnose the pain. If the pain is a tumor, the patient will not receive surgery nor be admitted to the hospital. They will be stabilized and released. Some in this condition go home and die. Read about the access and equity in our healthcare system in Health Attitude.