Over the past few years, there have been numerous efforts to pick away at the various rules that made up the Patient Protection and Affordable Care Act. First the individual mandate went away, once again allowing people to go uninsured without fear of facing a government fine. Then the White House began allowing insurance companies to sell more flexible, lower-cost plans that do not cover as much as was previously required by the ACA.
More recently, a federal judge declared much of the law wholly unconstitutional. According to CNN Health, such a legal decision would, in theory, invalidate the law in its entirety. Not surprisingly, the issue at the heart of the ruling - handed down by Texas District Judge Reed O'Connor in mid-December - is that the ACA's individual mandate was able to be included in the law because lawmakers counted it under Congress's tax power, which O'Connor said is no longer applicable. He further wrote in his decision that the individual mandate also violated the Interstate Commerce Clause, rendering it unconstitutional.
What's the fallout?
However, it's worth noting that Congress already repealed the mandate late last year as part of its massive tax overhaul, so it's unclear to many legal and health care experts how the ruling will actually affect the law, the report said. That's especially true because O'Connor apparently held off on releasing his decision - which had been ready for several weeks - until toward the end of the ACA's open enrollment period, as a means of having it dramatically change how insurers might do business while millions of Americans sought coverage on the federal and state-run health insurance exchanges.
Moreover, it's not as though this ruling will invalidate many of the changes to the health care system the ACA enacted, simply because the landscape of the entire industry is much different now, the report said.
"The ACA is pretty baked into our health care system now," Karen Pollitz, a senior fellow and expert on health reform and private insurance with the Kaiser Family Foundation, told CNN. "Making it go away is not that easy. The law is extensive and goes far beyond coverage and financial assistance for patients."
Nothing is final
In addition, Politz and others in the industry don't necessarily believe O'Connor's decision is going to stand, as legal scholars on both sides of the aisle apparently consider the decision a "vast overreach" that will likely be overturned when it is kicked up to higher courts for appeal, CNN added. The parties in the lawsuit, which include 17 states in favor of the ACA, have until shortly after the new year to decide how to proceed.
"Legal scholars consider the decision a 'vast overreach.'"
Indeed, if the states decide to appeal the decision - and experts agree it's likely that this will happen, given the its shaky legal founding - it would be heard by the U.S. Court of Appeals for the 5th Circuit, according to The Washington Post. If it goes beyond that point it would go to the U.S. Supreme Court, which would not be able to hear the case before October 2019 at the very earliest.
Once it gets there, the Supreme Court is, by and large, expected to be "skeptical" of the ruling, the Post noted. The projected swing vote in the decision would be Chief Justice John Roberts, who has twice dismissed such challenges already, once in 2012 and again in 2015. Furthermore, even if things are being decided strictly on party lines in this case, the anti-ACA view is hardly uniform on this particular ruling. Many conservative legal scholars who previously supported attempts to repeal the law have written that this ruling, especially, is specious, throwing into doubt whether Roberts, at a minimum, would agree with O'Connor's decision. At issue in particular seems to be the fact that O'Connor's decision threw out the entire ACA and not the individual mandate.
What's happening now?
This ruling was released the day before open enrollment came to a close, so it was already jarring for many Americans at a time when there is plenty of uncertainty about the future of the ACA. In the meantime, the U.S. Department of Health and Human Services has already affirmed that it will continue upholding the ACA's various rules and regulations as it has since the Trump administration began in early 2017, CNN noted.
But even in states where the law has broad support from lawmakers, such as Massachusetts, there is a potentially notable impact, according to The Boston Globe. After all, states receive billions of dollars from the federal government through the ACA's Medicaid expansion, so if the law is thrown out in its entirety that could dramatically impact millions of low-income Americans who rely on the program for their health care.
Dr. Donald Berwick, senior fellow at the Institute for Healthcare Improvement in Boston, who served as administrator of Medicare and Medicaid under President Barack Obama, said the total repeal of the ACA would be a "disaster" simply because of how disruptive it would be, which is why Massachusetts - with a massive part of its economy coming from the health care sector - is among the states that intend to bring the case all the way to the Supreme Court if needed.
With that said, despite the fact that there are significant worries among consumers, who may not really have an understanding of the underlying legal issues, experts say it's important for consumers and those in the industry to keep in mind that nothing is settled yet, the report said. Millions of people have already signed up for coverage in 2019 via the exchanges and they will still receive subsidies to defray premium costs (if they qualify) and won't see their current plans altered much, if at all, by this decision.
"There won't be much change in the immediate future."
A huge impact
Nonetheless, the decision has some consumer advocates concerned about the future impact it will bring, even if there won't be much change in the immediate future, according to the Hartford Courant. Some even see the issue as potentially being a long-term positive because while the ACA has in some ways been popular with Americans- even many of those initially opposed to it - there are certainly aspects of it that many parties would like to change for the better so that it's more effective for consumers, insurers, health care providers, government agencies and so on.
Indeed, the fact that even popular aspects of the law - such as guaranteed coverage for preexisting conditions and the potential for tighter controls on drug prices - would be thrown into serious question if the law were totally repealed, and shows why it's important that the law is upheld as-is for now, Julie Rovner of Kaiser Health News told PBS. Not only did those rules go into place, but so too did things like the aforementioned Medicaid expansion, as well as renewing the Indian Health Service, extending grants for training more medical professionals and fund community health centers.
"All of that would go away if the entire law was actually struck down," Rovner told PBS. "That is so embedded now into the health care system, that it really would cause an enormous, enormous disruption. [It's] almost hard to overstate how much of a disruption it would be."
With all this in mind, perhaps the best thing for consumers and professionals in the health care sector to do as the case winds its way through the court system is to keep an eye on proceedings as they unfold. In the case of health insurers, having contingency plans in place for all outcomes is probably a necessity, and having those efforts currently underway would be advisable.