A federal district judge in Texas ruled the entire Affordable Care Act was unconstitutional, siding with a group of 20 Republican state attorneys general in their effort to invalidate the 2010 law — former President Barack Obama's key legislative achievement.
Rather than defending the ACA, the Trump administration sided with the plaintiffs in the case — asking the court specifically to strike down the provision that protects Americans with pre-existing medical conditions.
Judge Reed O'Connor of the U.S. District Court for the Northern District of Texas, who was appointed by former President George W. Bush, said that when Republicans repealed the individual mandate tax penalty a year ago, that rendered the remainder of the law unconstitutional.
That means other provisions of the law — like the measures that protect Americans with pre-existing conditions, expanded Medicaid and created the regulatory pathway for the U.S. Food and Drug Administration to approve lower-cost versions of biologic therapies, or biosimilars — would also be struck down if the Texas ruling is upheld.
The ruling would also nix the provision that closed the coverage gap in the government's Medicare Part D prescription drug program, meaning seniors and disabled Americans would have to pay more for their medicines.
"Many of this administration's healthcare priorities, including testing new models for paying for prescription drugs in Medicare, are only possible because of authority conferred by the ACA," Rachel Sachs, an associate professor of law at the Washington University in St. Louis, noted on Twitter.
The administration is mulling over testing whether an international pricing index payment model could lower the costs of expensive injectable medicines covered by Medicare.
That demonstration project would be run by the Center for Medicare and Medicaid Innovation, which was established by Congress in 2010 under the ACA.
The ACA has been challenged before, but the Supreme Court upheld the law. All five justices who kept the law in place in a 2012 ruling, including Chief Justice John Roberts, remain on the court.
California Attorney General Xavier Becerra said he and a coalition of Democrats will appeal the ruling.
"Today's ruling is an assault on 133 million Americans with preexisting conditions, on the 20 million Americans who rely on the ACA for healthcare and on America's faithful progress toward affordable healthcare for all Americans," Becerra said in a Dec. 14 statement. "The ACA has already survived more than 70 unsuccessful repeal attempts and withstood scrutiny in the Supreme Court. Today's misguided ruling will not deter us: our coalition will continue to fight in court for the health and wellbeing of all Americans."
The Democratic heads of three House Committees, who will take control of those panels in January 2019 — Energy and Commerce's Frank Pallone of New Jersey, Ways and Means' Richard Neal of Massachusetts and Education and the Workforce's Bobby Scott of Virginia — condemned the Texas judge's ruling as "reckless," saying it "endangers the lives of millions of Americans who are going to lose their healthcare."
"It is an ideological decision in a case that has no legal merit," the lawmakers stated.
They noted that Democrats plan to intervene in the case come January 2019.
Last month, Rep. Jerry Nadler, D-N.Y., who will take the helm in January 2019 of the House Judiciary Committee, said he plans to investigate the Trump administration's refusal to defend the ACA — a duly enacted federal statute.
The Texas ruling came the night before the Dec. 15 deadline for Americans to enroll in private healthcare plans through the ACA's marketplace — a year when sign-ups have been significantly lagging.
The Centers for Medicare and Medicaid Services reported on Dec. 12 that just over 4.1 million Americans had enrolled by the sixth week, down 11.7% from the same period last year, when nearly 4.7 million people had signed up.
"It is curious that this court decision is being issued the night before the last day of ACA open enrollment, which is expected to be the biggest day of sign-ups," Larry Levitt, senior vice president at the nonpartisan nonprofit Kaiser Family Foundation, tweeted.
Last year, the Trump administration slashed the ACA marketplace's annual open enrollment period in half — shortening it from three months to six weeks.
The Department of Health and Human Services also substantially cut grants for navigators — people who help enrollees understand their options and help them with paperwork to obtain financial help and assess provider networks. In addition, the agency sharply reduced the funds for advertising about the enrollment period.
Earlier this week, the Republican head of the Senate health committee, Sen. Lamar Alexander, R-Tenn., said he wanted to pivot away from trying to get anything done on fixing the ACA's individual healthcare insurance market and focus instead on reining in costs, acknowledging the coverage issue has been a loser for Republicans.
For now, legal experts emphasized the ACA stays in place because there is no injunction, with the Trump administration still responsible to implement it.
University of Michigan law professor Nicholas Bagley said he was "gobsmacked" by the Texas judge's ruling. "This is insanity in print, and it will not stand up on appeal," Bagley tweeted.