On Friday, a federal judge in Texas struck down the Affordable Care Act, otherwise known as Obamacare, but that doesn’t mean the law is dead – yet. Here’s what you need to know.
What did the judge decide?
Texas District Judge Reed O’Connor ruled that the part of the law that mandated that people get coverage was unconstitutional, and because the mandate was “essential to and inseverable from the remainder of the ACA,” the rest of the law would have to be thrown out, as well.
“Individual Mandate can no longer be fairly read as an exercise of Congress’s Tax Power,” O’Connor wrote, “and it is still impermissible under the Interstate Commerce Clause – meaning the Individual Mandate is unconstitutional.”
In December 2017, as part of tax reform legislation, Congress essentially eliminated the mandate, reducing the penalty that Obamacare required if someone didn’t have insurance. The penalty goes down to $0 in 2019.
Didn’t Congress eliminate the individual mandate?
It was that change that gave the Texas attorney general, along with 17 Republican state attorneys general and two governors, an opportunity to file a lawsuit arguing that if this key part of the law was eliminated, the entire law is unconstitutional.
The Trump administration refused to defend Obamacare in court. California and 16 other Democratic-led states stepped in to argue that the mandate was constitutional and that even without it, the law should still stand.
On Saturday, the last day of open enrollment, a red banner on top of HealthCare.gov, where people sign up for Obamacare, read, “Court’s decision does not affect 2019 enrollment or coverage.”
Will people still get their health care through the insurance exchanges?
President Donald Trump celebrated the ruling Friday, but the White House noted later in the day that, pending appeals, the “law remains in place.”
The deadline to sign up for coverage was Saturday in most states. People getting their insurance for 2019 this way are still good to go.
It’s unclear what will happen to those customers in the future. Nearly 10.3 million people got their insurance this way in 2018.
If the ruling stands, millions may have to find insurance another way, if they can. Obamacare was created in part so people could find a plan that was affordable and would cover them even if they had a pre-existing condition.
Obamacare also expanded who was eligible for Medicaid. If the law is completely struck down, their insurance could also be in jeopardy. Nearly 10 million additional Americans gained coverage through the Medicaid expansion.
Who else would be affected?
“The ACA is pretty baked into our health care system now,” said Karen Pollitz, a senior fellow and expert on health reform and private insurance with the Kaiser Family Foundation. “Making it go away is not that easy.”
Essentially, anyone who uses the health care system could be affected. The nearly 2,000-page law radically reshaped the system.
Under Obamacare, employers with 50 employees or more had to offer benefits to those who work more than 30 hours a week.
The law also changed the quality of care that insurance had to cover. Under Obamacare, health insurance plans must carry 10 essential benefits that include emergency services, hospitalization, pregnancy, mental health, prescription drugs, lab work, rehab, outpatient care, preventive care such as birth control, mammograms and cholesterol tests. Pediatric services such as dental and vision care are also included.
People up to the age of 26 were also allowed to stay on their parents’ health insurance under Obamacare.
Obamacare eliminated lifetime limits, meaning policies can’t be maxed out. And the 133 million people with pre-existing conditions could no longer be turned away or charged more by insurance companies. Previously, even people with acne could be denied coverage.
It improved benefits for Medicare Advantage enrollees, slowed the growth of payment rates to hospitals and offered preventive health care free to Advantage patients.
And there are initiatives that go far beyond what you’d see with your own insurance. Obamcare set up plans to address waste, fraud and abuse in the system. It created a CMS innovation center that tests ways to save money on health expenses. It held hospitals more accountable. It created taxes that helped pay for the programs. There were new financial disclosure rules for doctors and pharmacists. Nonprofit hospitals had to conduct community assessments and make sure they were meeting the health needs of the community.
“The law is extensive and goes far beyond coverage and financial assistance for patients,” Pollitz said.
What options would there be without the law?
It’s unclear and too soon to tell whether the alternative – buying health insurance on your own – would cost more, but that is likely for those who are older and sicker. Younger and healthier people would likely be able to buy cheaper but skimpier policies, as in the past. Insurance companies could also go back to offering plans that cover very little and denying people coverage if they have pre-existing conditions.
What happens next?
“Most legal scholars I heard this weekend, regardless of their politics, seem to think this decision was vast overreach and would be overturned if reviewed by higher courts,” Pollitz said. “We will have to see what happens.”
The parties in the lawsuit will meet this week and have to file briefs by January 4 to determine the next steps. The judge did not grant an injunction, so it’s unclear whether this is a final judgment on the law or if it could be stayed or appealed.
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The office of California Attorney General Xavier Becerra, who called the ruling “an assault,” suggested that the state would appeal. The case could go to the US Court of Appeals for the 5th Circuit, a conservative court. If that court upholds the ruling, it could make its way to the US Supreme Court.
It’s a legal battle that could take years.
Correction: A previous version of this story incorrectly stated the number of Republican attorneys general and governors who filed the lawsuit with the Texas attorney general.