Happy rainy Tuesday, everyone.

I’ve just been educating myself on the hierarchy of the U.S. courts system, because this morning’s conflicting rulings about premium subsidies gave me whiplash. What I’ve found/been told by people who understand these things is that the U.S. Court of Appeals for the federal circuit, located in D.C., is on the same level as the 12 regional circuit courts, like the 4th Circuit Court of Appeals, located in Virginia.

Isn’t learning fun?

OK. So, story numero uno: Two federal court rulings came out today that add confusion to health reform; Kaiser Health News has a good round-up of helpful articles. A three-judge panel from the U.S. Court of Appeals in D.C. ruled, in Halbig v. Burwell, that states using the federal healthcare.gov exchange are not eligible for premium subsidies from the federal government because the text of the health reform law says the exchanges must be established by the state. This would affect the 36 states that did not open their own exchange (or at least the 27 states that are fully on the federal exchange; nine states have a state-federal partnership and the impact on them is unclear) — Washington is not one of them — and jeopardize health coverage for the estimated 5 million people there who have already purchased subsidized insurance.

A few hours later, a three-judge panel for the 4th Circuit Court of Appeals in Virginia ruled the exact opposite in King v. Burwell (almost the same case), saying ambiguity in the law does make states on the federal exchange eligible for premium subsidies. Basically, it’s a big mess, and it’s likely that the Supreme Court will have to take up the case. For now, the Obama administration says it will seek an “en banc” hearing at the U.S. Court of Appeals so it can get a decision from the full 11-judge court. While that’s pending, the administration says subsidies will not be affected for the millions of people who have already purchased coverage.

Also, one of the 4th Circuit judges used pizza as an analogy for his opinion, so, that’s cool.

Whew, OK. It’s hard to find anyone in my health care circle on Twitter who *isn’t* talking exclusively about these decisions today.

But here’s something my coworker Kate passed along: This Vox.com story talks about how states that have restricted access to anti-psychotic drugs for Medicaid patients have higher populations of mentally ill people — primarily schizophrenics — in their prison populations. So the cost of the drugs, which the “prior authorization” Medicaid restrictions were meant to rein in, has just been shifted to prisons.

I’m gonna call it good for this post today. Questions and comments can go in the box below, or you can email me directly, and as always, read earlier entries on the Pulse blog.